Bilateral tibial bone stress injury

Case contributed by Dr Ammar Haouimi


Localized pain that occurs during exercise at the left mid-tibial region.

Patient Data

Age: 10 years
Gender: Female

Periosteal reaction of the mid-tibial shaft more pronounced on the left. No tibial or fibular fracture.

Circumferential periosteal edema of the proximal and mid-tibial shaft with extensive adjacent bone marrow edema, seen as a low signal on T1 and high signal on STIR with enhancement on postcontrast sequences. No soft tissue component or abscess formation. no intracortical fracture.

MRI of both legs shows the same features in the right tibia with periosteal and bone marrow edema involving mainly the middle third of the tibial shaft.

Case Discussion

MRI features of bilateral tibial bone stress injury grade 3 according to Fredericson grading system.

Initially, this child had x-rays of both legs and an MRI of the left leg in another institution. The AP radiograph was reported as normal and the MRI features of the left leg an appearance suggestive of osteomyelitis vs Ewing sarcoma and a biopsy was requested.
Before the biopsy, this file was sent to us for a second opinion. we have reviewed the file. The laboratory investigations including the inflammatory markers (CRP and ESR) were normal, which excludes the possibility of osteomyelitis. Also, the MRI feature was not that of a tumoral process and in our opinion, this was a bone stress injury.
We have questioned the child and the pain seems to be bilateral more marked on the left, which occurred after participating in a long walk competition of several kilometres in the past few days. A few MRI sequences (coronal T1, coronal and axial STIR) of both legs were performed in our institution that confirms the bilateral involvement that is suggestive of bone stress injuries.

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