Anterior Tibial Stress Fracture - Please Help!!!

[sarah81]

Hi all,

I am after some much needed advice. I have been diagnosed with an anterior mid shaft stress fracture of my tibia. I have seen a SP, OS and physio. After more than 4 months on crutches (total non weight bearing) there has been no relief. There is a large lump on the front of my shin (Osteoid osteoma - ruled out) which flares up if I put any weight through my leg. Still have severe night pain as well and point tenderness. I have had bone scan, MRI, CT, xrays and blood tests. MRI & CT confirmed SF, bone scan came back with stress but no hot spot. The talk is now possibly heading towards have a rod drilled into my tibia. Everyone I speak to says that they have never seen this type of SF before and that it is very rare. I am an avid sportsgoer and am shattered that I am unable to play sport. Has anyone seen this before or know of the op being suggested? Just want to make sure I am doing the right thing.

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[ingedik]

I'm sorry, I haven't heard of anything like it before, just thought I should reply so that you know your post has been seen..

Keep us up to date with how you're doing, we might learn something new from you regarding stressies.

Regards

[physiobob]

Interesting post. Sounds like you've had all the right investigations. It is somewhat bizarre that the stress fracture did not show on a bone scan. One might suggest that it is NOT a stress fracture, or not active at least if that was negative. Bone scans show up just about any increase activity in the bone and can be overly positive as a result.

That begs the question, what is painful in the bone but doesn't show up on a bone scan? Myeloma doesn't always show on a scan but you normally see something on a plain x-ray over the area. Do you have any private health insurance? A PET scan might be useful.

All that said if the diagnosis is definitive then you need more time. Perhaps why the bone isn't healing so fast also needs addressing. Diet in terms of what you eat, but also how much of that is getting to the point needing it. Other systems could be draining the calcium from the diet thus slowing your healing process. A good dietitian might assist with this.

[sarah81]

Thank you both for your replies, was starting to feel unloved. It has been such a long and draining process (5 1/2 months of non-weight bearing), I have seen another surgeon since - who thought I had been misdiagnosed, he had a senior radiologist look at all of the films (who then also questioned the stress fracture diagnosis). Last week I had another bone scan - which showed a def hot spot, the senior radiologist then completed a supplementary report from all films and confirmed the initial diagnosis. The report said that it involved the fascia??? rather than being a compaction stress fracture and was a chronic healing anterior stress fracture. So it looks certain that I will be having the IM nailing op. Has anyone had experience with this op before? Ie. recovery time, rehab, how much time non-weight beaing, cast/brace??? etc. Thanks again for your replies - much appreciated.

[physiobob]

Can you ask the surgeon to tell you how the intramedullary rod will assist to heal this issue? I suspect it is to stimulate bone healing but creating a false fracture in the bone? Having the fascia involved maybe there is some compartment issues in there are well. Perhaps this was the original issue? Some type of fascial release may be required as well if that was the case.

I'd be interested in peoples opinions (including the surgeons) as I have not had anyone who has undergone this procedure before. Have you tried magnetotherapy/magnetic therapy for accelerated bone healing. We used to use that all the time to speed up fracture healing. If you're on the North Shore of Sydney then the Narrabean Sports Physio practice at the NSW Academy of Sport have one.

P.S for interest I attached images of a stress fracture with and without intramedullary rod. These came from http://www.orthosupersite.com

[sarah81]

Thank you very much for your reply. You have given me some food for thought and I have now have a list of questions for the surgeon on Friday. I will let you know how I go - my doctor, physio and surgeon did some research into a bone stimulator but they decided it was not appropriate for my case. (it was also a 2 month wait to get clearance from Private Health Insurance and a cost of $8000). The IM rod op does worry me a bit, but they assure me that its the only way to go. The frustrating thing is that they keep saying that they have never seen this type of stress fracture before it is only 2% of all stress fractures. What do they mean when they mention the fascia? Thanks again for your replies, I truly appreciate all of your help.

[sarah81]

Met with the surgeon today I have been booked in to have a tibia biopsy and ostectomy - he is going to try this before the IM rod - and hopefully it heals. So I am so happy now that I have a plan at least. The op is on October 18th so still hopping around on crutches til then.

[physio2]

Hi sarah81,

Have you tried low intensity pulsed ultrasound or electrical stimulation when you had physiotherapy? I am not sure why your medical team does not want to use a bone stimulator. Since you are going to have surgery anyway, there is nothing to loose. The high cost is unfortunate because this is something you could benefit from. Where I am from, a bone stimulator would have been utilized by now, likely resulting in assisted fracture healing. Surgery is always the last resort. In my opinion, regarding a tibial stress fracture, one should only have surgery after all conservative treatments have been exhausted.

[sarah81]

Thanks for the reply physio2. Since my last thread, I have actually been going in for daily treatments using the bone stimulator for the last 2 1/2 weeks. My awesome physio ended up organising one through one of the AFL clubs - at no charge. No change as yet..but we will continue to do it for a little while yet. I realise that surgery is the last option - but I have been complete non weight bearing (on crutches) for the last 6 months - so the surgeon sees this as the only way forward - as there has been no improvement at all. I am just hanging out to start walking again and get my life back! Hopefully the surgery will provide this.

[physio2]

Hi sarah81,

If the bone stimulator does not work, you might want to use it for longer periods of time and if that does not work you might want to ask your surgeon about bone grafting.

The IM rod should work, however there have been cases where the athlete has jumped up and then landed on the affected leg, thus causing the IM rod to bend resulting in a fractured tibia. I am not saying this is common, but it is something to be aware of.

[sophie411]

Hi Sarah81,
I was just wondering what's happened with your anterior tibial stress frature? How are you doing now and if you are better what ended up working for you? I have the same diagnosis and both opinions I've sought so far believe surgery with rod is the best way to go.

[sarah81]

Hi Sophie411,

Sorry to hear about your diagnosis. I wish I could put a positive spin on it for you...I had surgery in October last year, where I had a mass removed from my leg (they were initially worried about it...but biopsy came back all clear). They believe that this mass may have contributed to the lack of healing. They also stripped the tibia down and completed a tibial release procedure they then cut a wedge out of my tibia to try and stimulate bone growth. The rehab from the surgery has been a long and frustrating one, I was still on crutches until March, then downgraded to a moonboot - which I got off 2 weeks ago. I am now able to walk unaided. We will not know if the surgery has been a success yet - they were trialling this procedure and hoping it would heal so that I could avoid the IM rod. Still same rehab but a little less intrusive. If successful sport is still another 2 yrs off if at all. They did say that it was biomechanics so could come back.

Good luck - hopefully your recovery is a little speedier than mine.

[sophie411]

Dear Sarah81,
Wow! You have really had a hard time! I'm so sorry. I'm glad to hear you're finally out of a cast and a boot. I am still trying to figure out what to do but my options don't look too plentiful. Thank you for replying. Please feel free to share any advice or experience. Thank you.

[physiobob]

Hi Sarah and thanks for your update. Your issue is a great one for us here on the forum and it is interesting that after all of these discussions the results thus far have followed some of the initial ideas presented here. I also feel that our discussions have assisted you to be better informed and have provided some alternative ideas and therefore questions for your treating clinicians. It seems that has proved fruitful as the current approach and surgery seems entirely appropriate. We'd love any images of the post surgery x-rays you might be able to post. Perhaps that is the role of a forum such as this. To have the time to provide more input into possibilities that the injured then take to their treating clinician. In a way we are also providing a broader team input into these case studies in the real world as they happen. Pretty exciting really

Do continue to let us know how you get on.