Tibial Stress Fractures: Specificity of Focal Tenderness to Palpation
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Published:
Apr 30, 2025
Keywords:
Stress fractures, semiology, tibial fractures, tibial stress
Main Article Content
Abstract
Introduction: Stress fractures are common among military recruits and athletes. When involving the leg, they are typically characterized by tenderness in the medial tibial region. The inconsistency and imprecision of previously described clinical examination maneuvers highlight the need for this study, which aims to evaluate the sensitivity and specificity of tibial palpatory pain patterns.
Materials and Methods: A series of 19 patients presenting with 31 painful episodes in the leg between 2012 and 2014 was analyzed. Patients experiencing tibial pain during military training were included, while those with a history of trauma were excluded. A physical examination was performed, mapping painful tibial points using a grid divided into nine zones and classifying them into three patterns: vertical, transverse, and focal (single point). All patients underwent radiographic and scintigraphic imaging.
Results: Of the total patients, 63% were women and 36.8% were men. A total of 31 lesions were identified (64.5% in women, 35.5% in men). Radiographs were negative in all cases, whereas scintigraphy confirmed 22 (71%) stress fractures and 9 (29%) cases of periostitis. The transverse and focal pain patterns were the most sensitive (40.91%). The focal pattern was observed in 29% of cases and was exclusively associated with stress fractures.
Conclusions: Focal tenderness to palpation was present in 100% of cases with stress fractures, demonstrating its high specificity as a clinical sign. This finding highlights its diagnostic value in evaluating tibial stress fractures.
Materials and Methods: A series of 19 patients presenting with 31 painful episodes in the leg between 2012 and 2014 was analyzed. Patients experiencing tibial pain during military training were included, while those with a history of trauma were excluded. A physical examination was performed, mapping painful tibial points using a grid divided into nine zones and classifying them into three patterns: vertical, transverse, and focal (single point). All patients underwent radiographic and scintigraphic imaging.
Results: Of the total patients, 63% were women and 36.8% were men. A total of 31 lesions were identified (64.5% in women, 35.5% in men). Radiographs were negative in all cases, whereas scintigraphy confirmed 22 (71%) stress fractures and 9 (29%) cases of periostitis. The transverse and focal pain patterns were the most sensitive (40.91%). The focal pattern was observed in 29% of cases and was exclusively associated with stress fractures.
Conclusions: Focal tenderness to palpation was present in 100% of cases with stress fractures, demonstrating its high specificity as a clinical sign. This finding highlights its diagnostic value in evaluating tibial stress fractures.
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How to Cite
Coria, H. E., Ameriso, N., Blanco, D., Fedún Rodríguez, E., Masaragian, H., Mizdraji, L., Perin, F., Rega, L., & Sartorelli, D. (2025). Tibial Stress Fractures: Specificity of Focal Tenderness to Palpation. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 90(2), 123-130. https://doi.org/10.15417/issn.1852-7434.2025.90.2.2089
Section
Clinical Research
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https://doi.org/10.1016/j.csm.2005.08.015
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https://doi.org/10.2165/00007256-199724060-00006
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hallazgos patológicos asociados en reclutas. Rev Asoc Arg Ortop Traumatol 2024;89(2):143-9.
https://doi.org/10.15417/issn. 1852-7434.2024. 89.2. 1868
11. Moran DS, Heled Y, Arbel Y, Israeli E, Finestone AS, Evans RK, et al. Dietary intake and stress fractures among
elite male combat recruits. J Int Soc Sports Nutr 2012;9(1):6. https://doi.org/10.1186/1550-2783-9-6.
12. Armstrong DW, Rue JPH, Wilckens JH, Frassica FJ. Stress fracture injury in young military men and women. Bone 2004;35(3):806-16. https://doi.org/10.1016/j.bone.2004.05.014
13. Milgrom C, Zloczower E, Fleischmann C, Spitzer E, Landau R, Bader T, et al. Medial tibial stress fracture diagnosis and treatment guidelines. J Sci Med Sport 2021;24(6):526-30. https://doi.org/10.1016/j.jsams.2020.11.015
14. Devas MB. Stress fractures in athletes. Proc R Soc Med 1969;62(9):933-7. PMID: 5823819
15. Sanderlin BW, Raspa R. Common stress fractures. Am Fam Physician 2003;68(8):1527-32. PMID: 14596439
16. Matheson GO, Clement DB, Mckenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in
athletes. Am J Sports Med 1987;15(1):46-58. https://doi.org/10.1177/036354658701500107.
17. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Am J Sports Med
1995;23(4):472-81. https://doi.org/10.1177/036354659502300418
18. Milgrom C, Gila di M, Stein M, Kashtan H, Margulies JY, Chisin R, et al. Stress fractures in military recruits. A
prospective study showing an unusually high incidence. J Bone Joint Surg Br 1985;67(5):732-5.
https://doi.org/10.1302/0301-620X.67B5.4055871
in military personnel. J Scie Med Sport 2023;26(Suppl 1):S14-21. https://doi.org/10.1016/j.jsams.2023.04.006
2. Bhatnagar A. High incidence of stress fractures in military cadets during training: A point of concern. J Clin Diagn Res 2015;9(8):RC01-3. https://doi.org/10.7860/JCDR/2015/12535.6282
3. Harrast MA, Colonno D. Stress fractures in runners. Clin Sports Med 2010;29(3):399-416. https://doi.org/10.1016/j.csm.2010.03.001
4. Gallo RA, Plakke M, Silvis ML. Common leg injuries of long-distance runners: anatomical and biomechanical
approach. Sports Health 2012;4(6):485-95. https://doi.org/10.1177/1941738112445871
5. Beck BR. Tibial stress injuries. Sports Med 1998;26(4):265-79. https://doi.org/10.2165/00007256-199826040-00005
6. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987;15(2):168-71. https://doi.org/10.1177/036354658701500213
7. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician
2011;83(1):39-46. PMID: 21888126
8. Young AJ, McAllister DR. Evaluation and treatment of tibial stress fractures. Clin Sports Med 2006;25(1):117-28.
https://doi.org/10.1016/j.csm.2005.08.015
9. Brukner P, Bennell K. Stress fractures in female athletes. Sports Med 1997;24(6):419-29.
https://doi.org/10.2165/00007256-199724060-00006
10. Coria HE, Fedún Rodríguez E, García D, Masaragian H, Mizdraji L, Perin F, et al. Fracturas de tibia por estrés y
hallazgos patológicos asociados en reclutas. Rev Asoc Arg Ortop Traumatol 2024;89(2):143-9.
https://doi.org/10.15417/issn. 1852-7434.2024. 89.2. 1868
11. Moran DS, Heled Y, Arbel Y, Israeli E, Finestone AS, Evans RK, et al. Dietary intake and stress fractures among
elite male combat recruits. J Int Soc Sports Nutr 2012;9(1):6. https://doi.org/10.1186/1550-2783-9-6.
12. Armstrong DW, Rue JPH, Wilckens JH, Frassica FJ. Stress fracture injury in young military men and women. Bone 2004;35(3):806-16. https://doi.org/10.1016/j.bone.2004.05.014
13. Milgrom C, Zloczower E, Fleischmann C, Spitzer E, Landau R, Bader T, et al. Medial tibial stress fracture diagnosis and treatment guidelines. J Sci Med Sport 2021;24(6):526-30. https://doi.org/10.1016/j.jsams.2020.11.015
14. Devas MB. Stress fractures in athletes. Proc R Soc Med 1969;62(9):933-7. PMID: 5823819
15. Sanderlin BW, Raspa R. Common stress fractures. Am Fam Physician 2003;68(8):1527-32. PMID: 14596439
16. Matheson GO, Clement DB, Mckenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in
athletes. Am J Sports Med 1987;15(1):46-58. https://doi.org/10.1177/036354658701500107.
17. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Am J Sports Med
1995;23(4):472-81. https://doi.org/10.1177/036354659502300418
18. Milgrom C, Gila di M, Stein M, Kashtan H, Margulies JY, Chisin R, et al. Stress fractures in military recruits. A
prospective study showing an unusually high incidence. J Bone Joint Surg Br 1985;67(5):732-5.
https://doi.org/10.1302/0301-620X.67B5.4055871