Medial tibial stress syndrome

Case contributed by Dai Roberts
Diagnosis almost certain

Presentation

Recent increase in running as training for a marathon. Complains of pain in medial leg, worse with activity.

Patient Data

Age: 40 years
Gender: Male
mri

Two oil bead markers have been placed, identifying the region of symptoms within the medial aspect of the leg.  On the axial PDFS weighted sequence, high signal is adjacent to the posteromedial tibial periosteum, with minor intermediate T1 and PD (T2) signal in the adjacent tibial cortex.  No line of low signal on the T1 weighted images to confirm a complete fracture.  FIndings are most in keeping with medial tibial stress syndrome.

Additionally, there is likely a longitudinal split tear of the peroneal brevis tendon in the retromallelor groove, and attenuation of the ATFL due to a prior thickness tear, which have both been partially imaged.

Annotated study

mri

Annotated image, with the green arrows pointing to the high signal adjacent to the posteromedial tibia periosteum. 

Case Discussion

Medial tibial stress syndrome can be regarded as a type of stress fracture.  These injuries occur when there is abnormal stress/ load on normal bone, as opposed to fragility fractures where there is normal stress on abnormal bone. Medial tibial stress syndrome can present with a spectrum of findings, ranging from a normal MRI, to a linear fracture line evident on T1 weighted sequences 1. These cases often only show subtle periosteal changes, which can be confused with traversing vessels.  Bright fluid signal is characteristically seen on the medial aspect of the tibia, and this can extend both anteriorly and/ or posterior.  

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