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 remodeling

• 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