Tibial stress fractures are the most common stress fracture, seen in runners, jumpers and military recruits. Posteromedial compression side fractures usually heal with activity modification, while anterior tension side fractures (the dreaded black line) are prone to nonunion and may need intramedullary nailing.

Epidemiology

Most common Stress Fracture
- Accounts for >50% of Stress Fractures
Common overuse injury in runners & jumpers
Mid-tibial shaftStress Fractures
- Occur in dancers
- Occur in jumping athletes

Differential Diagnosis

Shin Splints
Exertional Compartment Syndrome

History

Nocturnal pain

Examination

Extremely painful focal area of tibia
Provocative manoeuvres
- Pain on application of vibrating tuning fork
- Pain elicited on heel thump or >Hop Test”
- Pain with local ultrasound at 2.5 to 3 W/cm2
  - Not recommended currently for initial diagnosis
Common locations of Stress Fracture
- Children: Anterior proximal one third of tibia
- Adults: Junction of middle & distal third of tibia

Investigations

Tibial Stress Fracture (Shin Splints), radiograph of the tibia showing subtle periosteal reaction at a fracture — Radiograph of the tibia showing subtle periosteal reaction at a fracture. Image by Mohamed Jarraya, Daichi Hayashi, Frank W. Roemer, Michel D. Crema, Luis Diaz, Jane Conlin, Monica D. Marra, Nabil Jomaah and Ali Guermazi, Wikimedia Commons, CC BY 3.0.

X-ray with cone down view
- Horizontal lucency (dreaded black line)
  - Transverse fracture through entire anterior shaft
  - Seen more often in jumping sports
  - Higher likelihood of nonunion
Triple phase bone scan
- Focal hot spot at point of maximal tenderness
Magnetic Resonance Imaging (MRI)

Management

Consider Aircast splinting
Cast mid-shaft fractures until pain-free
Surgical repair indicated for delayed healing >6 months

Prognosis

Anterior fracture with more non-union than anteromedial

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.