Presentation
Started intense physical training (running) in the preceeding months. Presented with severe, dull leg pain worse around the inner aspect of both shin bones worsened by weight bearing. Upon physical examination tenderness and mild swelling in the area of maximum pain. Stress fracture?
Patient Data
Subtle, circumscribed periosteal reaction is visible around the medial aspect of both tibiae (see magnified key image). On the right it demonstrates a disorganized, hazy appearance, whilst on the left a single layer pattern can be observed.
On focused US periosteal reaction and adjacent soft tissue irregularity corresponds to the painful, mildly swollen area.
Findings are altogether in line with medial tibial stress syndrome due to the recent intense running training on hard surface.
Magnified comparison images of the US and x-ray appearance of the periostal reaction on both sides (orientation made identical for visual clarity).
Case Discussion
Subtle periosteal reaction of the tibial cortex in the context of chronic mechanical overloading is a discrete but important sign of stress injury. While the radiographs are often inconclusive, focused interrogation of the tibial cortex with US can easily be performed also offering immediate clinical correlation with the area of maximal tenderness.