Medial tibial stress injury

Case contributed by Dr Shailaja Muniraj


Sportsman with dull pain in the right lower leg, worsens during activity.

Patient Data

Age: 35 years
Gender: Male

There is a small intracortical signal change noted across the posteromedial aspect of proximal tibial shaft, suggestive of fracture. There is significant marrow edema extending from metaphysis to mid diaphysis.

Adjacent periosteal reaction noted in the form of subtle edema. Also seen is callous formation. Intramuscular edema noted within the soleus, flexor digitorum and tibialis posterior.

Loco-regional skin thickening with subcutaneous edema noted. Skin marker noted at the antero-medial aspect of upper calf.


The fracture line is confirmed. The callous formation is better appreciated. Also observed is the course and shape of the nutrient canal in the axial images.

Case Discussion

In this classical case, we can identify the fracture line, periosteal edema, callus formation and fluid in the surrounding loco-regional muscles. These are features suggestive of grade 4 medial tibial stress syndrome (Fredericson MRI classification).

If it is a radiological scenario of isolated tibial marrow edema

  • correlate with lab findings - rule out osteomyelitis
  • if there is endosteal scalloping with a soft tissue mass, consider the possibilty of pathologic fracture, secondary to neoplasm
  • if there is muscle atrophy, stress fractures can still occur as chronic muscle fatigue can lead to cortical weakening due to osteoclastic remodelling

  • the nutrient canal should not be confused for a fracture line, as it is rounded in appearance on axial images. Also it courses obliquely towards the distal end of tibia (as seen in the above CT axial images).

Special thanks to Dr HT Gururaj

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Case information

rID: 60629
Published: 28th May 2018
Last edited: 11th Sep 2018
Inclusion in quiz mode: Included
Institution: Prima diagnostics india

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