STRESS
FRACTURES
OF
OR
M.
Shin
soreness,”
Atlantic)
are
seriously
used
interfere
The
other
“shin
terms
with
symptoms
shin,
which
gradually
A
typical
symptoms
and
the
days,
At
activity
and
any
first
the
shorter
has
ceased.
attempt
With
find
that
The
type
of
fracture
until
VOL.
pain
pain
purpose
stress
40B,
days’
will
various
athlete
a run.
The
Western
of
forms
feels
side
shin
gnawing
of
become
the
of
the
which
can
of running.
a dull
intensity
ultimately
rest,
but
the
pain,
the
rest
from
in this
this
paper
of
only
(Fig.
MAY
with
produce
1958
pain
causes
recurs;
of
2,
off
Finally
fracture
stage
NO.
passes
running
involving
a later
of
the
so
pain
the
pain,
severe
one
in
at
that
first
or
mild,
running
or
of
reaction
distances
at
a few
the
the
on
condition
FIG.
1
the tibia in “shin soreness.”
Two months
after the onset of
is visible
in the antero-posterior
view;
in the lateral view
line can be seen passing up through
one cortex only.
stress
fracture
a periosteal
and
Horse”
London
continued.
the fracture
shorter
and
ATHLETES
Hospital,
a painful
in the
first
end
Middlesex
“Charlie
performance
the
IN
ENGLAND
the
describe
at
towards
over
be
cannot
Registrar,
to
insidiously:
occurs
increases
sprinting
training
HASTINGS,
(and
athletes
TIBIA
SORENESS”
B. DEVAS,
splints”
by
start
“SHIN
Orthopaedic
Senior
Fornerlv
THE
the
one
sport
cortex
athlete
a whole
show
which
of
at
once
feels
season
that
the
bone,
the
night,
training
better
of
training
to
diagnose
and
soreness”
is
not
running.
for
and
“shin
is difficult
further
persists
during
pain
the
way
with
which
continues
severe
is to
tibia
recurs
some
but
does
has
and
Over
hours
tries
to
the
after
not
prevent
be
discontinued.
to run
again,
days
athletic
sleep,
only
to
is spoilt.
is caused
because
apparent
by
it is an
in
the
a particular
incomplete
radiographs
I).
227
228
M. B. DEVAS
TABLE
DETAILS
OF
Case
SIXTEEN
PATIENTS
Sc
wim
Age
number
X
STRESS
I
FRACTURES
OF
THE
of
Length
TIBIA
CAUSING
SORENESS”
“SHIN
ort
Time
off
(years)
history
p
sport
Running
4 months
I
M
15
5 weeks
2
F
16
Unknown
3
M
18
4
M
20
5 weeks
Running
5
M
19
2 months
Running
6
M
21
2 months
Athletics
2 months
7
M
27
3 months
Running
Unknown
8
F
20
3 weeks
Running
3 months
9
M
23
(L)
4 weeks
(R)4weeks
10
M
15
11
M
17
12
M
13
Many
weeks
School
sports
School
sports
Runn’n
Well
after
biopsy
5 months
4 months
3
1 month
Unknown
g
1
months
Running
More
than
3 months
3 weeks
Running
More
than
4 months
19
Unknown
Running
More
than
3 months
M
18
3 weeks
Running
More
than
3 months
14
M
23
2 months
Running
2 months
15
M
17
Unknown
Running
3 months
16
F
19
5 months
Ballet
“Some
weeks”
TABLE
STRESS
Age
FRACTURES
and
type
OF
THE
Athletes
Children
4-16 years
2
Adults
16-28
2
TIBIA
Unknown
II
RECORDED
Recruits
1938
FROM
ONWARDS
Other
Total
20
22
18
46
26
years
Ballet
dancers
20-26
years
5
Adults
28-44 years
0
Adults
5
44-68
years
Total
78
(From
Hansson 1938, Roberts and Vogt 1939, Weaver and Francisco
Nordentoft
1940, Pfahler
1941, Hartley
1942, Krause
and
Thompson
1943, Robin
and Thompson
1944; Proctor,
Campbell
and Dobelle 1944; Wolfe and Robertson
1945, Mann 1945, Leveton
1946, Kelly and Murphy
1951, Singer and Maudsley
1954, and
1940,
Burrows
1956.)
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
STRESS
FRACTURES
OF THE
TIBIA
IN
ATHLETES,
OR “SHIN
SORENESS”
229
2
FIG.
3
months
after the onset of “ shin soreness
“
the radiographs
of a twenty-one-year-old
haze of periosteal
new bone on the medial side of the tibia, which is barely visible in this
3-The
same athlete
as in Figure
2. After a further
month the new bone formation
is
obvious,
but no fracture
line is visible.
FIG.
Case 6. Figure
athlete
showed
reproduction.
2-Two
a faint
Figure
CLINICAL
This
at the
study
radiological
It must
and
but
they
have
on
Hospital
I gives
details
twenty-six
the
stress
recruits
while
cases
treated
of
seventy-eight
symptoms
number
Clinic
and
of the diagnosis
that radiological
are not seen in many
been diagnosed
and
Table
the
a considerable
Athletic
confirmation
be emphasised
summarises
Of
is based
Middlesex
MATERIAL
of stress
changes
of” shin
early.
cases
in
this
the
A typical
aged
trained
E
example
of shin
twenty-one
who
as a middle-distance
40 B,
VOL.
NO.
which
Table
“shin
soreness”
of whom
there
definite
invariably
a late
manifestation,
are
in all
other
typical
changes.
For
comparison,
tibia recorded
in the
literature
only
said
have
three
seen
was
are
to
respects
Table
since
developed
II
1938.
their
running.
SYMPTOMS
man
fracture.
are almost
radiological
of
with
in sixteen
soreness”
with
fractures
included
of patients
elsewhere,
2,
MAY
1958
soreness
worked
runner.
AND
is shown
as a clerk
SIGNS
in Case
in an office;
6 in Table
in the
evenings
I.
The
and
patient
at weekends
was
a
he
M. B. DEVAS
230
4
(Fig. 3) the fracture
the onset of symptoms.
FIG.
Case
6-Three
weeks
after
the
previous
since
For
the
end
two
months
became
which
seen he noticed
got worse
until
It is nearly
a little pain in the lower
the day before
attending
four
right shin
hospital,
months
towards
when
it
severe.
showed
Examination
part
being
gradually
before
of a run,
line is visible.
radiograph
of the
right
a healthy
shin.
This
young
area
was
man,
very
who
complained
tender
and
of pain
slightly
in the
antero-medial
oedematous.
A radiograph
showed
a slight haze of periosteal
new bone (Fig. 2).
Elastic
adhesive
strapping
was applied
to the leg from
the toes to below
the knee,
and
the patient
was instructed
to rest from all sport but to continue
with his office work.
A month
later
there
was considerably
more
new bone
formation
(Fig.
3).
Pain
was still present
on
activity
but
Three
a fracture
of the
not
tibia
(Fig.
again.
the
physical
only
Table
running
considered.
4).
The
After
sign
that
children.
in school
I).
A below-knee
the
was
and
pain
inwards
and
six weeks
thickening
most
in the
the
the
had
gone
there
tibia
were
in
patients,
to
complain
of
showed
new
bone
formation,
A
was
performed,
and
then
cortex
and
were
of the
patients
younger
applied.
radiographs
postero-medial
Radiographs
biopsy
began
of
was
and
tenderness
a further
some
plaster
removed
was
Among
sports
walking
plaster
upwards
I shows
school
Table
rest.
later
running
training
being
at
weeks
no
the
their
late
aged
in the
and
was
histological
‘teens
or
sixteen
about
full
early
who
JOURNAL
OF
three
doing
centre
much
(Case
of a neoplasm
BONE
AND
and
5).
twenties,
were
begin
activity,
was
the
possibility
third
to
(Fig.
preparations
THE
clearly
lowermost
allowed
of fracture
shin,
the
the
despite
site
a girl
pain
patient
symptoms
at the
demonstrated
of
2,
was
reported
JOINT
to
SURGERY
STRESS
FRACTURES
OF
THE
TIBIA
IN
ATHLETES,
6-The
final healing
of a “shin
soreness”
Stress
postero-medial cortex of the tibia was involved.
show
a
there
were
centre
chronic
inflammatory
no further
of the
shaft
of the
The
lesion.
symptoms
tibia
(Fig.
6).
anteriorly,
OF
SEVENTEEN
in the
This type of fracture
case
whereas
TABLE
SITE
illustrated
fracture,
fracture
This
SORENESS”
231
5
FIG.
Case
OR “SHIN
united
quickly
is unusual
the
preceding
is always
most
figures.
after
in that
common
Only
the
incomplete.
operation
the
lesion
site
is near
and
was
in the
or
at the
the site
of the
III
STRESS
FRACTURES
Level in tibia
Type
of lesion
Lowermost
Complete
crack
Periosteal
reaction
in one cortex
only
.
Total
junction
of the
middle
seventeen
fractures
summarised
in
VOL.
40 B,
NO.
Table
2,
and
under
MAY
II.
1958
lowermost
consideration,
thirds
third
Middle third
third
Uppermost
9
1
1
5
1
-
14
2
1
postero-medially.
and
Table
IV
Table
gives
the
ill
shows
level
of
those
fractures
232
M. B. DEVAS
FIG. 6
Case 2-A
girl who did much running
in school sports developed
pain and swelling
of the shin. The early radiograph
(left) showed
subperiosteal
new bone formation.
A
month later the bone formation was considerably more marked (right).
This site
is more typical
of the ballet dancer’s
fracture,
being anterior
and in the middle
of the shaft of the tibia.
The
fractures
occurring
uppermost
in recruits in the
by
(1956)
Burrows
all
in athletes
are concentrated
third.
In the series of stress
the
fractures
were
in the
TABLE
SITE
OF STRESS
FRACTURES
OF THE TIBIA
middle
in the
fractures
third
of
IN SEVENTY-EIGHT
Lowermost
fracture
in
a ballet
in the lowermost
cortices
of fractures
dancer
.
.
PATIENTS
included
in
third of the tibia and,
this
third
series).
in common
tibia
REPORTED
(as
tibia and
recorded
was
the
stress
IN THE
LITERATURE
in tibia
Middle
6
.
the
of the
dancers
IV
Level
Number
lower
part
in ballet
third
Uppermost
7
The
with
stress
the
65
fractures
type
third
of
seen
middle
in recruits,
age
involve
occur
both
of the tibia.
THE
JOURNAL
OF
BONE
AND
JOINT
5URGERY
STRESS
FRACTURES
OF THE
TIBIA
IN
ATHLETES,
OR “SHIN
233
SORENESS”
DIAGNOSIS
Diagnosis
radiological
is difficult
because
many patients
seen early
changes
sufficient
to confirm
the diagnosis.
There
is usually
a history
of pain becoming
it is felt only at the end of a run, but it gradually
a history
of
or even
felt
an
injury
of a sudden
in the
front
immediately
onset
and
lower
in an early
Examination
before
of pain.
The
oedema
may
be
present
early,
patients
by
done
“springing”
by straining
of
tibia
of the surgeon)
placed
side
of
leg at
of
leg,
held
at the
the
level
knee
and
the
third
that
occurs
fracture
of the
middle
Maudsley
(1954).
tibia
previously
recorded
across
earliest
of the
bone
immediately
outside
which
the
later
the fracture
little or no
be
seen,
cortex,
only
The
The
(Figs.
medial
of stress
uppermost
the
third
lowermost
by Singer
of the
of the tibia.
a slight
loss
10).
area
Later
becomes
In this patient
the
seen and photographed
In the
in the
the
site is on
the swelling
and
this
thickens
and
side of the bone
one
line
to disrupt
of the
and
of fracture
is not,
views
the
will
radiographs
spreads
as constant
often
show
do
not
new
show
bone
from
those
with
MECHANISM
direction
NO.
of the line of fracture
as to open
2,
bone
MAY
1958
the postero-medial
a linear
inwards
fracture
(Fig.
formation
OF THE
suggests
surface
the tibia.
of
“shin
shin
is
the
Usually
soreness”
fracture
from
comparable
a definite
crest
the
because
is on
In the
the
stress
formation
the
of
only
a
type
a varying
distance,
but at first there
is
a faint
haze of subperiosteal
new bone
finally
and
as the
despite
repeated
examinations
radiological
change
was the
subperiosteal
such a direction
until
being involved.
runs upwards
usually
however,
over
Later
the
swelling
the antero-medial
surface
of the tibia and is difficult to see and
photograph.
The patient
illustrated
was
ballet dancer.
bone
dense,
7
FIG.
lesion
the periosteum
cortical
bone.
Sometimes
40 B,
fracture
appears
disturbance
onset
of symptoms,
in whom
the only
VOL.
of
new bone can be seen
a hard
thickened
prominence.
direction
The
to
cortex
cortex
a little fluffy
condenses
to form
athletes.
Oblique
(Fig.
11).
new
the
on
as a transverse
9 and
this
when
described
show
around
be
(such
outer
stress fractures
part or whole
of the shaft
stage
there
may be only
density
can
aged
Most
some
is pressed
and
be
to
the
against
ankle,
in recruits
and
in
has
tenderness;
this fulcrum
a fracture
through
the
the tibia
is opened
and pain occurs.
Radiological
appearances-This
type
differs
from
the
more
common
fracture
stage
a fulcrum
as the knee
the
a later
This
against
At first
is never
but
not
A little
pain
tibia.
without
onset,
the subcutaneous
the swelling
can
the
the
the
at
recover
tenderness
border,
is felt.
and
there
is a definite
thickening
surface
of the tibia.
Sometimes
seen (Figs.
7 and 8).
It is possible
to reproduce
by rest
is generally
part of the leg.
case will elicit
of the
shin, usually
the medial
necessarily
exactly
where
the pain
treated
more
severe
during
several
months.
comes
on earlier
and earlier.
There
the
pain
and
before
until
is visible
postero-medial
fracture
any
nearly
12). Table
III
of a smaller
cortex.
of the
fracture
three
in the
line
months
separates
or longer
fibula
in
is visible
after
the
the patients
amount
of
crack.
FRACTURE
that usually
a strain
of the tibia
at its lower
has
end,
been
and
applied
sometimes
in
M. B. DEVAS
234
the
postero-lateral
surface.
In one
instance
the
upper
postero-medial
border
affected
and the fracture
line was directed
downwards
and outwards
(Fig.
It is possible
that the strong
calf muscles
which
arise from the middle
the back of the shaft of the tibia may, when used at their greatest
strength,
bend
slightly
(1956)
in such
that strong
a way
that
muscular
it bows
forwards.
activity can
draw
It has been shown
the fibula
towards
the
of the
tibia
13).
and upper
cause
the
by Devas
tibia, and
and
this
was
part
tibia
of
to
Sweetnam
is perhaps
Ii
The
the
the
cause
same
type
of stress
the
tibial
fracture
of
ballet
dancer’s
individual,
of the fibula
and it seems
also
14 and
fractures
(Figs.
FIG.
8
is transverse
anterior
cortex.
fracture
in athletes.
likely
that
and
These
two types
the same
mechanism
straight,
through
the
of fracture
occur
is responsible
in
for
15).
TREATMENT
is all-important
Rest
abstention
Elastic
patient
keep
from running
and
adhesive
strapping
is usually
symptoms
with
able
to
probably
the
all activity
applied
that
from
follow
ordinary
daily
only
a sedentary
activities
essential
part
causes
symptoms.
the toes to below
occupation.
a
In
below-knee
of treatment.
the
knee
patients
walking
By rest
appears
who
plaster
to help;
continue
will
is meant
allow
to
the
have
them
about.
Physiotherapy
into
and
the
fracture
does
site
not
in one
help
patient
until the
had
fracture
no success.
has
united,
THE
JOURNAL
and
hydrocortisone
OF
BONE
AND
injected
JOINT
SURGERY
to
STRESS
FRACTURES
OF
THE
TIBIA
IN
FIG.
The early stages
of a stress fracture
months
VOL.
40B,
later
NO.
2,
healing
MAY
is taking
1958
place.
The fracture
OR “SHIN
235
SORENESS”
9
in the lowest
FIG.
Two
ATHLETES,
third
of the tibia in a middle-aged
man.
10
is transverse
and
involves
both
cortices of the tibia.
236
M. B. DEVAS
When
there is no longer
any pain or tenderness
to start gentle
training,
which
is gradually
increased
provided
there
are
no further
at the fracture
to full training
site the patient
is allowed
over four to six weeks,
symptoms.
DISCUSSION
A
fracture
and
Francisco
and
have
Kelly
been
shin
soreness
of the type described
1940,
Pfahler
and Murphy
recognised
to
1936;
Symposium
Tucker
1950,
Krause
1951) but
previously.
strains
1952, Woodard
FIG.
and
reported
by
Thompson
the association
The text-books
of muscles
and
Athletic
Injuries,
on
Knight
1941,
has been
and
on
five occasions
Wolfe
and
(Weaver
Robertson
1945,
with “shin
soreness”
does not appear
to
and papers
on athletic
injuries
ascribe
such like conditions
Medical
Press
and
1954,
others
1943,
Fletcher
(Lloyd,
Circular
Deaver
and Eastwood
1937;
Thorndike
1948,
1956).
11
12
FIG.
Figure lI-An
medial
runner,
oblique view showing the periosteal
new bone formation
on the posteroborder of the lowest third of the tibia. Figure 12-This
patient, a middle-distance
had typical
“shin
soreness” but the only radiological
change observed was a little
periosteal
Stress
indeed,
fractures
Aleman
in
new
of the tibia
1929 noted
bone
formation
have
that
been
there
towards
known
were
the back
of the tibial
shaft.
for many
years,
particularly
reported
one hundred
cases
in recruits;
of so-called
“periostitis
tibiae
ab excercito”
each
year
in the Swedish
army,
but he considered
the
condition
an “insufficiency
fracture.”
Since
then many
reports
on stress
fractures
of the tibia have appeared,
but it was not
until shortly
before
the second
world
war that the condition
began
to be recognised
for what
it is.
Vogt
and
Even
1939,
this
more recently
Weaver
and
would
histological
those
and
be
material
Francisco
misleading
the radiological
of a low-grade
inflammatory
from
1940)
unless
biopsy
performed
in two reported
cases
was thought
to show a form of chronic
the
appearances
clinical
picture
of stress
is understood,
fractures
do
(Roberts
and
inflammation
because
not
differ
both
greatly
the
from
process.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
STRESS
was
One
that
FRACTURES
OF
of the patients
in this
of chronic
inflammation,
It seems
likely
had injuries
a comparable
that
the
five
THE
series
but
TIBIA
IN
ATHLETES,
was subjected
the histological
ballet
dancers
OR “SHIN
SORENESS”
237
to biopsy
and the pathological
section
was not available
for
recorded
by
of a similar
nature,
for the symptoms,
signs
course
to that of shin soreness,
although
Burrows
and progress
the site and
(1956)
report
study.
in great
detail
appear
to have followed
radiological
appearance
I
13
FIG.
A girl aged twenty had the typical
signs
and
symptoms
of” shin soreness”
except
that the site was in the uppermost
third of the tibia. The fracture line runs downwards
and inwards but is only through one cortex. There is some evidence from the
radiographs
and the history that there has been a previous
stress fracture
in the
lowest third of the same tibia.
of the
lesion
Burrows’s
suggests
description
a different
was
mechanism.
published,
and
“shin
soreness”
type of stress fracture.
The interesting
feature
about
this
only
one
VOL.
40 B,
cortex
NO.
of the
2,
MAY
tibia.
1958
Other
forms
The
at
that
fracture
of stress
case
recorded
time
in athletes
fracture
was
in this
series
considered
was
to
be
is that it is incomplete,
of the
tibia
have
gone
seen
an
before
atypical
involving
on not
only
M. B. DEVAS
238
14
FIG.
14-Five
Figure
medial
cortex
onset of symptoms
in this athlete a typical
15-Five
weeks
later
this is more
obvious.
had a stress fracture of the fibula.
to involve
both cortices
but on occasions
have developed
case was mentioned
by Burrows
(1956)
in a ballet dancer,
and
Vogt (1939),
Hartley
(1942),
Krause
and Thompson
A close similarity
exists
between
stress
fractures
those
seen
in the
fibula.
people,
the series
being comparable
attention
in
A form
symptoms
and
might
be difficult
In
sufficient
This
reported
to those
1940.
of chronic
treatment,
to strain
anterior
in the
is also
early
tibial
to
be
emphasis
must
site.
Provided
resume
training
within
is
recognised
and
a few
sport
seen
stages
syndrome
very
has
like
before
those
radiological
absolute
immobilisation
the fracture
are eliminated;
cases,
but great
at the fracture
not
similarity
haze of new bone
The
(1943)
in athletes
in the
stress
months;
allowed
but
to
been
of
when
advice
continue,
THE
patient
one such
by Roberts
(1946).
in the
tibia
and
of middle-aged
by
Mayor
soreness,
and
had
(1956).
The
differentiation
occurred.
necessary
strapping
and other
the athlete
is neglected
many
this
Singer
and Maudsley
(1954)
to which
Burrows
first drew
changes
sport
early
fractures;
reported
fractures
suggested
shin
is seen on the
season
and Leveton
that occur
is probably
not
elastic
adhesive
be placed
on rest from
the diagnosis
is made
previous
into complete
and others
were
in the lowest
third
of the tibia
by
seen in the lowest
third
of the fibula
appear
signs
15
FIG.
weeks
after
the
of the tibia. Figure
until
months
of
JOURNAL
OF
provided
the forces
is sufficient
in most
activities
causing
pain
may well be able to
late,
or
disability
BONE
AND
the
condition
may
JOINT
ensue.
SURGERY
FRACTURES
STRESS
OF THE
TIBIA
IN
ATHLETES,
OR
SHIN
“
SORENESS
239
“
SUMMARY
2.
A type of stress fracture of the tibia in runners is described.
This type of fracture,
associated
with
shin soreness,”
has
3.
The
I
.
not
“
signs,
symptoms
and
radiological
appearances
been
are discussed,
and
It is a pleasure to thank
me to use their patients
preparation
my former chiefs, Mr Philip Wiles and Mr Philip Newman,
for this study;
and I am also most grateful
to Mr Wiles
report.
It is also a pleasure
to thank the staffofthe
Radiological
ofthis
Hospital
for their co-operation
ALEMAN,
0. (1929):
recognised
treatment
before.
is outlined.
for their kindness
in allowing
for his help and advice in the
Department
ofthe Middlesex
and assistance.
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