Vol.:(0123456789)
1 3
Archives of Orthopaedic and Trauma Surgery (2019) 139:25–33 
https://doi.org/10.1007/s00402-018-3035-5
ORTHOPAEDIC SURGERY
A complete posterior tibial stress fracture that occurred 
during a middle-distance running race: a case report
Jun Komatsu1  · Atsuhiko Mogami2 · Hideaki Iwase3 · Osamu Obayashi2 · Kazuo Kaneko1
Received: 5 August 2018 / Published online: 7 September 2018 
© The Author(s) 2018
Abstract
Posterior tibial stress fractures are more frequent than anterior tibial stress fractures, and they are considered to have a good 
prognosis for returning to sports; cases leading to a complete fracture are rare. A 17-year-old male involved in high school 
athletics middle-distance running had a 3-week history of pain with training. He was running up to 300 km/week on streets 
and cross-country in an even distribution. He had posterior tibial stress fractures, but despite the lower leg pain, he contin-
ued running. One year later, he was brought to the emergency department after having sustained an injury to the right lower 
leg while running in a middle-distance race; bilateral tibial stress fractures, with one side complete and the opposite side 
incomplete, had developed simultaneously. This relatively rare case of bilateral posterior stress fractures, with one side a 
complete fracture and the opposite side an incomplete fracture, that was treated surgically via exchange intramedullary nail-
ing is reported. The patient could begin light jogging from 3 months after surgery and was without symptoms at 5 months 
after surgery. He could resume middle-distance racing after 1 year. Posterior tibial cortical fractures are more common and 
respond better to conservative treatment than anterior tibial stress fractures, and they are a common fracture type in runners. 
We believe that close, careful follow-up is necessary if patients continue excessive training.
Keywords Stress fractures · Running · Overuse injuries · Posterior tibial stress fracture · Runner-type stress fracture · 
Intramedullary nailing
Introduction
Highly committed athletes commonly develop stress frac-
tures. In the general population, long-distance running is 
a particularly common form of exercise, physical activity, 
and leisure activity. It has become increasingly popular due 
to its easy accessibility and a growing interest in disease 
prevention. Although many positive health effects have 
been attributed to distance running, it can cause injuries. 
Repetitive tissue stress frequently causes overuse injuries 
affecting the lower extremities [1]. Adolescent athletes place 
high physical demands on their bodies that vary depending 
on the given sports activity, which may cause stress or avul-
sion fractures due to repetitive microtrauma that overloads 
the bone. A runner who suddenly increases the intensity and 
duration of training is at risk for developing a stress fracture 
[2]. A tibial shaft stress fracture is the most frequent such 
fracture in athletes [3, 4]. The tibia is reported to be the most 
common site of stress fractures, accounting for 35–56% of 
all stress fracture injuries [5].
Tibial stress fractures can be classified into two groups 
depending on the location, anterior and posterior, causing 
anterior and posterior/posteromedial stress fractures, respec-
tively. Anterior stress fractures occur in sports with frequent 
jumping, and they are characterized by prolonged healing 
due to excessive fibrous growth [6]. Anterior cortical frac-
tures are less common than posterior stress fractures [7], 
and they often heal poorly due to constant tension exerted 
by relatively poor vascular and posterior muscular forces; 
they are located on the anterior, tension side of the tibial 
 * Jun Komatsu 
 
jkomatsu@juntendo.ac.jp
1 
Departments of Medicine for Motor Organs, Juntendo 
University Graduate School of Medicine, 2-1-1 Hongo, 
Bunkyo-ku, Tokyo 113-8421, Japan
2 
Department of Orthopaedic Surgery, Juntendo University 
Shizuoka Hospital, 1129 Nagaoka, Izunokuni 410-2295, 
Shizuoka, Japan
3 
Department of Bio-Engineering, Juntendo University 
Institute of Casualty Center, 1129 Nagaoka, 
Izunokuni 410-2295, Shizuoka, Japan
26
 
Archives of Orthopaedic and Trauma Surgery (2019) 139:25–33
1 3
shaft, and are prone to delayed union and nonunion [8]. In 
some instances, anterior tibial stress fractures can progress 
to complete fractures [9–11].
On the other hand, posterior tibial cortical fractures are 
more common and respond adequately to conservative treat-
ment, but they are a significant clinical problem for runners. 
In most cases, conservative treatment is sufficient, and sur-
gical treatment is very rarely needed. The most predomi-
nant type is the low-risk posteromedial cortex (compression 
side) stress fracture [3, 12, 13]. However, to the best of our 
knowledge, no previous reports have specifically examined 
complete posterior tibial stress fractures.
A relatively rare case of simultaneous bilateral posterior 
tibial stress fractures, in which one side was a complete frac-
ture and the opposite side was an incomplete fracture, which 
was treated surgically via exchange intramedullary nailing, 
is reported.
Case report
A 17-year-old male involved in high school athletics middle-
distance running presented with a 3-week history of pain 
with more training. He was running up to 300 km/week on 
streets and cross-country in an even distribution. Although 
he had taken analgesics, the pain during exercise did not 
improve, and he presented to our emergency department 
with lower leg pain (Fig. 1). There was no clear abnormality 
on the radiographs of the tibia, but STIR magnetic resonance 
imaging (MRI) confirmed a high-intensity area of the distal 
one-third of the tibia, and the diagnosis of stress fracture 
and shin splint was made. The patient was instructed to sus-
pend training, and the injury was treated conservatively with 
follow-up on an outpatient basis (Fig. 2). Follow-up radio-
graphs were checked at 2 and 3 months. With this treatment, 
the fracture healed with no complications, and he decided to 
return to running after 3 months. At 6 months, radiography 
showed thickening of the bone cortex in the back one-third 
of the right tibia and in the back of the distal part of the left 
tibia, so that he was again instructed to stop training (Fig. 3). 
However, he discontinued coming to the outpatient clinic on 
his own after 6 months.
He was then seen in the emergency department, having 
sustained an injury to the right lower leg while running a 
middle-distance race, 1 year after the initial examination. He 
described how, when he had just started and passed through 
the first corner, he had felt a ‘‘snap’’ in his right calf, sud-
denly could not run, and fell and had to abandon the race. 
He said that his leg was deformed in an impossible direc-
tion. It became impossible to run because of the lower leg 
deformities, and he was brought to our emergency depart-
ment. He was admitted to hospital, and X-ray examination 
showed a greatly displaced oblique fracture in the proximal 
Fig. 1  Initial radiographs show suspected tibial stress fracture or shin 
splints. There is no clear abnormality in the radiographs of the tibia in 
the antero-posterior and lateral views. A Right side; B left side
27
Archives of Orthopaedic and Trauma Surgery (2019) 139:25–33 
1 3
1/3 of the left lower leg, but, fortunately, there was no open 
wound (Fig. 4). Before the race that day, the patient had 
not experienced any pain or discomfort in his left lower leg 
while running. In the emergency department, the primary 
assessment showed moderate direct and indirect tenderness 
of the opposite proximal tibia. There was no malalignment, 
swelling, or discoloration of the left lower leg.
The radiographs showed a full-thickness fracture of the 
proximal one-third posterior tibial shaft (Fig. 4). On MRI, 
T1-weighted imaging showed a high-signal area at the mid-
dle one-third and a low-signal on T2-weighted imaging, 
and STIR showed an abnormal high signal at the same site 
(Fig. 5). These findings suggested abnormalities such as 
edema and bleeding in the bone marrow. On bone scintig-
raphy, there was moderate accumulation in the vicinity of 
the left lower third of the thigh, so a left tibial stress fracture 
was diagnosed (Fig. 6).
Fig. 2  Initial coronal MRI scans diagnosed with a stress fracture 
show a strikingly wide low-signal intensity on the T1-weighted scan 
(A), and a high-signal intensity on the T2-weighted scan (B) and 
STIR fat-suppressed scan (C) in the localized bone marrow. The 
abnormal finding is more detectable on the STIR fat-suppressed MRI 
scan
28
 
Archives of Orthopaedic and Trauma Surgery (2019) 139:25–33
1 3
The following day, surgical treatment for the injury was 
performed under general anesthesia after written, informed 
consent was obtained from the patient and parents. In addi-
tion, the patient gave written, informed consent for pub-
lication of the case, including the accompanying images. 
At our institution, ethical approval is not required for 
reporting individual cases. Closed reduction and internal 
fixation of the radial shaft fracture were performed, with 
intramedullary nailing (10-mm-diameter, T2 Nailing sys-
tem, Stryker, Kalamazoo, MI) for both the left complete 
tibial fracture and the right tibial stress fracture (Fig. 7).
The injury was then treated conservatively, with 9 weeks 
in an ROM knee cast and no weight-bearing on the affected 
leg. Healing was monitored through a series of follow-up 
radiographs. With this treatment, the fracture healed with 
no complications. Although the patient was asymptomatic 
and clinical healing of the fracture was apparent 10 months 
after the nailing, a fracture line was still visible on radio-
graphs (Fig. 8). The patient could begin light jogging from 
3 months after the operation and was without symptoms at 
5 months. He returned to middle-distance racing after 1 year.
Discussion
If operative treatment is not performed, a stress fracture that 
is persistently painful may develop delayed union, nonun-
ion, or even a complete fracture. An established technique 
for treating delayed or nonunion tibial stress fractures is 
intramedullary nailing [14]. There are two types of tibial 
stress fractures, anterior and posterior, based on their loca-
tion. Furthermore, there are many frequent running-type 
stress fractures (posterior fractures), which are thought to 
resolve better than jumping-type stress fractures (anterior 
fractures), which often develop in field athletes. In particu-
lar, posterior tibial cortical fractures, which are more fre-
quent and show an adequate response to conservative ther-
apy, are often seen in runners. Ohnishi said that actually they 
were widely distributed proximally to distally including the 
middle third, so runner-type stress fractures are more likely 
to be generated from the posterior tibia [15]. The distance 
run per week can also be a factor in stress injuries. It has 
been shown that running more than 64 km/week (approxi-
mately 40 miles/week) is a significant risk factor for lower 
extremity injuries [16].
In the present case, the patient had posterior tibial 
fractures, but, despite the lower leg pain, he continued 
running, so that bilateral tibial stress fractures, with 
one side complete and the opposite side incomplete, 
occurred simultaneously. To the best of our knowledge, 
there have been no previous reports of a posterior tibial 
stress fracture with a complete fracture as in the pre-
sent case. Because the symptoms improve with rest for a 
short period of time, many patients may not seek treat-
ment. Moreover, there may be intrinsic elements, that 
are internal factors, which result in additional stresses 
to the bone. Such intrinsic elements include anatomical 
variations, footwear, running mechanics, training regi-
mens, and running surfaces, as well as individual health 
factors, such as poor bone health (osteoporosis and low 
Fig. 3  Radiographs of both legs 6 months after the initial visit to our 
hospital. Obtained 6 months after the first examination, callus forma-
tion is seen at the lateral and posterior side of the tibia in the antero-
posterior and lateral views. The arrows indicate callus formation at 
the lateral and posterior sides of the tibia
29
Archives of Orthopaedic and Trauma Surgery (2019) 139:25–33 
1 3
bone density) [17]. According to Reeder et al. [18], it is 
important to focus on the runner’s training regimen and 
history to identify potential injury-causing factors. A pes 
cavus foot is linked to stress fracture incidence; because 
this foot type is more rigid, it does not absorb shock and 
Fig. 4  Radiographs at the emergency department with deformity of 
the right lower leg. Full-length tibial radiographs were requested in 
keeping with the clinical picture, and they confirm complete tibial 
and fibular fractures of the right side. A Right-side tibial radiography 
and 3D computed tomography; B Left-side tibial posterior stress frac-
ture. Arrows indicate callus formation sites
30
 
Archives of Orthopaedic and Trauma Surgery (2019) 139:25–33
1 3
passes impact forces to the tibia, therefore, increasing the 
risk for a tibial stress injury [19].
Most patients with the symptoms of stress fractures 
reduce the distance, frequency, and intensity of their activ-
ities. Distance runners have an increased risk for stress 
fractures because of the high impact and repetitive loads. 
With repetitive mechanical loading of bone, cumulative 
bone strain can cause bone damage and stress fractures if 
net bone damage is chronically greater than bone repair 
[20]. Especially in runners, posterior tibial stress fractures 
occur commonly on the compressive posterior surface of 
the proximal and distal thirds of the tibia; these fractures 
can be considered low-risk fractures compared to anterior 
fractures and managed by relative rest. Nonsurgical treat-
ment of posterior tibial stress fractures begins with rest 
and stopping the aggravating activity. A stress fracture 
is a mechanical failure of the bone in which the activity 
of the osteoblasts cannot keep pace with the activity of 
the osteoclasts. Repetitive, cyclical loading of the bone 
with inadequate recovery occurs, and the bone is unable 
to repair itself between exercise sessions [18]. With heavy 
loading of a bone, microcracks may appear within the bone 
tissue. Such microcracks are thought to contribute to acti-
vating the remodeling process, which is required for adap-
tation of the bone to the functional demands on the tissues 
caused by loading. However, with excessive loading, either 
in magnitude or frequency, a stress fracture can develop 
due to the insufficient time for remodeling to repair the 
microcracks [6]. Unfortunately, the repetitive and high 
loading nature of running creates an ideal environment 
for the development of stress fractures. Furthermore, a 
complete fracture may occur due to large cracks.
In the present case, due to repeated periods of rest and 
resumption of competition, at 1 year, a complete fracture 
finally resulted. Restricting excessive exercise and ensur-
ing sufficient rest when lower extremity pain appears 
may have made it possible to return to racing at an early 
stage. The present case had an insidious onset, present-
ing with moderate clinical signs and symptoms; therefore, 
diagnosis might have been delayed by analgesic medica-
tion, resulting in a complete fracture. At the same time, 
intramedullary nailing was performed for the opposite 
tibial stress fracture to facilitate an early return to training.
In conclusion, our observations demonstrate that the 
posterior tibia stress fracture is a more frequent tibial 
stress fracture than the anterior stress fracture, and it 
is considered to have a good prognosis for returning to 
sports; although rare, there are cases that result in a com-
plete fracture, and when excessive training is continued, 
careful follow-up is needed.
Fig. 5  MRI of the left lower leg after right complete fractures. On MRI, STIR shows an abnormal high signal
31
Archives of Orthopaedic and Trauma Surgery (2019) 139:25–33 
1 3
Fig. 6  Bone scintigraphs show abnormal local uptake in the antero-
posterior (A) and postero-anterior (B) and lateral views of the right 
side (C) and left side (D) of the patient with stress fractures. Arrows 
indicate longitudinal linear uptake in the bone scintigraph views of 
the patient with stress fractures
32
 
Archives of Orthopaedic and Trauma Surgery (2019) 139:25–33
1 3
Open Access This article is distributed under the terms of the Crea-
tive Commons Attribution 4.0 International License (http://creat iveco 
mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribu-
tion, and reproduction in any medium, provided you give appropriate 
credit to the original author(s) and the source, provide a link to the 
Creative Commons license, and indicate if changes were made.
References
 1. Van Gent RN, Siem D, van Middelkoop M, van Os AG, Bierma-
Zeinstra SM, Koes BW (2007) Incidence and determinants of 
lower extremity running injuries in long distance runners: a 
systematic review. Br J Sports Med 41(8):469–480
 2. Ballas MT, Tytko J, Cookson D (1997) Common overuse run-
ning injuries: diagnosis and management. Am Fam Physician 
55(7):2473–2484
Fig. 7  Radiographs show 
fixation of both tibial fractures, 
complete and incomplete, with 
intramedullary nailing. Closed 
reduction and internal fixation 
of the radial shaft fracture were 
performed using intramedullary 
nailing for both the right com-
plete tibial fracture (A) and the 
left tibial stress fracture (B)
33
Archives of Orthopaedic and Trauma Surgery (2019) 139:25–33 
1 3
 3. Brukner P, Bradshaw C, Khan KM, White S, Crossley K 
(1996) Stress fractures: a review of 180 cases. Clin J Sport Med 
6(2):85–89
 4. Jones BH, Thacker SB, Gilchrist J, Kimsey CD Jr, Sosin DM 
(2002) Prevention of lower extremity stress fractures in athletes 
and soldiers: a systematic review. Epidemiol Rev 24(2):228–247  
 5. Pohl MB, Mullineaux DR, Milner CE, Hamill J, Davis IS (2008) 
Biomechanical predictors of retrospective tibial stress fractures in 
runners. J Biomech 41(6):1160–1165
 6. Bargfeldt C, Krogsgaard M, Rasmussen SW (2011) Stress fracture 
in combination with avulsion from the tibia in a marathon runner: 
a case report. Scand J Med Sci Sports 21(2):330–332
 7. Orava S, Hulkko A (1984) Stress fracture of the mid-tibial shaft. 
Acta Orthop Scand 55:35–37
 8. Orava S, Hulkko A (1988) Delayed unions and nonunions of stress 
fractures in athletes. Am J Sports Med 16:378–382
 9. Kaeding CC, Yu JR, Wright R, Amendola A, Spindler KP (2005) 
Management and return to play of stress fractures. Clin J Sport 
Med 15(6):442–447
 10. Martinez SF, Murphy GA (2005) Tibial stress fracture in a male 
ballet dancer: a case report. Am J Sports Med 33(1):124–130
 11. Plasschaert VF, Johansson CG, Micheli LJ (1995) Anterior tibial 
stress fracture treated with intramedullary nailing: a case report. 
Clin J Sport Med 5(1):58–62
 12. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-
Smith DR, MacIntyre JG (1987) Stress fractures in athletes: a 
study of 320 cases. Am J Sports Med 15:46–58
 13. Bennell K, Brukner P (1997) Epidemiology and site specificity of 
stress fractures. Clin Sports Med 16:179–196
 14. Hattori H, Ito T (2015) Recurrent fracture after anterior tension 
band plating with bilateral tibial stress fracture in a basketball 
player. Orthop J Sports Med 3(10):1–5
 15. Ohashi J, Goto T (2003) Stress fracture in the tibia in long-dis-
tance runners: fracture level in the tibia and radiographic charac-
teristics. Jpn J Orthop Sports Med 23(3):254–258 (In Japanese)
 16. Macera CA, Pate RR, Powell KE, Jackson KL, Kendrick JS, Cra-
ven TE (1989) Predicting lower-extremity injuries among habitual 
runners. Arch Intern Med 149(11):2565–2568
 17. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A (2001) 
Risk factors for recurrent stress fractures in athletes. Am J Sports 
Med 9:304–310
 18. Reeder MT, Dick BH, Atkins JK, Pribis AB, Martinez JM (1996) 
Stress fractures. Current concepts of diagnosis and treatment. 
Sports Med 22(3):198–212
 19. Bennell K, Brukner P (2005) Preventing and managing stress frac-
tures in athletes. Phys Ther Sport 6(4):171–180
 20. Warden SJ, Burr DB, Brukner PD (2006) Stress fractures: patho-
physiology, epidemiology, and risk factors. Curr Osteoporos Rep 
4:103–109
Fig. 8  Postoperative antero-posterior and lateral radiographs show newly 
healed tibial stress fractures. Postoperative radiographs show antero-pos-
terior and lateral low views. The patient was asymptomatic and clinical 
healing of the fracture is apparent 10 months after the nailing, and a frac-
ture line is hardly visible on the radiographs. A Right side; B left side

A complete posterior tibial stress fracture that occurred during a middle-distance running race: a case report.
Komatsu, Jun,Mogami, Atsuhiko,Iwase, Hideaki,Obayashi, Osamu,Kaneko, Kazuo