Stress Fracture of the Proximal Tibia

Stress Fracture of the Proximal Tibia, radiograph of the tibia showing subtle periosteal reaction at a stress fracture
Radiograph of the tibia showing subtle periosteal reaction at a stress 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.

Epidemiology

  • Teenagers, mostly athletic children
  • Proximal tibia is a common site of stress fracture in children
  • Associated with an increase in training load

Pathology

  • Repetitive loading exceeds bone remodelling capacity
  • Fracture often involves the posteromedial cortex of the proximal tibia
  • Anterior cortical tension side stress fractures carry a higher risk of non union

Clinical Features

  • Pain with activity, relieved by rest
  • Night pain may develop as it progresses
  • Localised tenderness over the proximal and middle tibia
  • Possible swelling or palpable periosteal thickening
  • Pain on hopping on the affected leg
  • Ask about menstrual history in girls

Investigations

  • Plain films may be normal early
  • Later films show periosteal new bone and endosteal sclerosis
  • Bone scan is sensitive
  • MRI shows marrow oedema and fracture line without radiation
  • CT defines the fracture line

Differential Diagnosis

Management

  • Rest from the provoking activity
  • Protected weight bearing if painful
  • Cast may be needed for persistent pain or poor compliance
  • Graduated return to sport once pain free and tenderness has resolved
  • Address training errors and nutrition
  • Consider vitamin D and relative energy deficiency in recurrent stress fractures

Prognosis

  • Good with rest
  • Investigate atypical lesions to exclude tumour

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