Today on the Doc On The Run podcast, we’re talking about how the most important tibial stress fracture detail is location.
In this episode, we’re talking about tibial stress fractures. Tibial stress fractures are often something you get diagnosed with when you thought you had maybe shin splints or ankle pain, or even a sprained knee. You can get a problem with the tibia in different places, but the location is really the most critical piece when you’re trying to figure out whether or not it’s safe for you to run. All right, so let’s talk about this.
When you think about the location of the stress fracture, again, we’re talking about the leg, right? If you’re looking at your foot and you got your knee here, and you’ve got your kneecap up here, you have your tibia or your shinbone, and tibia is over here, fibula is over there, toes down here, talus bone is there and all the other stuff you don’t really care about in terms of bones in the foot. There’s three places that you can actually get a tibial stress fracture.
If you have aching pain and all of your pain is here in the middle of the tibia, then that is most often going to be misdiagnosed as shin splints. Now, if you get one of these fractures, the reason it’s bad is that when it cracks, we have to actually put a rod in your tibia. We start up in the knee. We actually put a big rod straight down your knee and then we put some screws down here, and sometimes there’s some screws up here, couple different kinds of rods. You do not want a rod inside your tibia. That is called an intramedullary rod because the medullary canal is the center part of the tibia and when you get a tibial fracture right in the middle of your leg, anywhere in this region, that’s really the best way to fix it. It’s not strong enough to put a plate and screws on it.
If it’s really bad and it’s continuing to get worse and worse and worse, you could conceivably break it there. But actually, of all the three kinds of tibial stress fractures, I’m most likely to let you run if you have one here. But again, that doesn’t mean that I told you to run so don’t go telling somebody that I told you to run because I haven’t even talked to you yet. Don’t take this as advice. I’m just telling you what I do and the way I think about these things. You do not want to fracture there, but it’s the least likely to actually break in that location. There are a couple of other places that you can get it.
Your femur, of course, you have the femoral condyles sitting here. Your femur is huge and all the pressure is on top of the tibia. And you can get actually pain up here where you’re getting this thing that’s called, this one is obviously your shin, up at your knee. This is actually called the tibial plateau. The tibial plateau is where your femur sits on top of there and rotates back and forth when you move your knee. Now, if you get a tibial plateau fracture, this is a very, very, very bad thing.
In fact, when I was in residency, there’s a guy I was working with, we did some reconstructive ankle surgery on him. We had to take a bunch of bone out from up here and put it in here. And what happened was the doctor took so much bone out of that area just beneath the cartilage surface on the top of the tibia that when the patient was actually walking to his car after the surgery, he stepped on it abruptly. He actually kind of slipped off his crutches and forcibly landed on it, and it caused a tibial plateau fracture where the whole top of the tibia caves in.
You do not want to do that. That is a bad, bad, bad, bad thing because it can ruin your knee forever. You might need a total knee replacement. It’s very, very bad. You do not want that. I don’t treat knees, but I can tell you that even if I did, I would never let anybody run with a stress fracture that’s in the tibial plateau because you could have that whole thing collapse and cave in. That’s number two, up at the knee. Now, the third one is down here. And if we blow this up so you can kind of see it better, when we’re looking at the ankle where you’ve got the inside ankle bone is the tibia over here. That big bump you feel like if you’re looking at your feet and you feel a big bump on the inside of your ankle, right here or here, that is the end of the tibia.
You have the fibula bone comes down and sits over here like that on the outside. The big lump on the outside of your ankle is the fibula, and this is the end of the tibia. Now, if you have pain down in your ankle, if you’re told that you have a tibial stress fracture, and I have had patients call me, they don’t actually know where it is, but you’re actually getting a crack right here like that? That’s a bad thing. I would never in a million years let you run on this even if I thought that it might not break. Why? Because, when it breaks, you then have a real live ankle fracture and it displaces.
If you had one of these, and maybe your doctors told you this, if you’ve got one of these, and if you’re looking at it from the side, that’s a bad foot but you get the idea. This is your heel bone, talus sitting on top of there, and the end of the tibia is over here. Basically, what we do is when you have one of these fractures that’s starting across here, we just go in and we put two screws like through little incision under x-ray in the operating room, couple little screws in there, 50 millimeter screws just go right up across there like that and make it stable. Why? Well, because then it can’t break.
If you have a stress fracture down at your ankle and some doctor tells you that you need surgery, your doctor’s not trying to make a Mercedes payment or something, they actually are trying to protect you. Why would that be effective in runners? I know you always talk about how bad it is when runners have surgery, when they use cast, when they use crutches too long, they use fracture walking tibial boots too long. So, why would I recommend surgery if you had this and why would I agree with your doctor if your doctor told you to do it? Number one, it’s way more stable and you can move way, way, way sooner.
The whole goal with a running injury, whether it’s a tibial stress fracture, an ankle fracture or an ankle sprain or anything else, is to maintain your running fitness. It takes a long, long time to build up your running fitness and you lose it very quickly. So, if you have surgery to put two screws across that tibial stress fracture down at your ankle, then it’s very stable and you can start training a whole lot sooner and maintain a whole lot more fitness.
In short, if you have a tibial stress fracture down at your ankle, that’s a bad thing. Don’t mess with it and don’t do anything stupid. Make sure you get the proper advice. If you have a shin splint type issue where it kind of comes and goes and it’s mild, I might actually let you run on that but not without figuring out the severity of your injury very specifically first. And up by your knee, if that’s a tibial stress fracture up at your knee where you’re going to get a tibial plateau fracture, never in a million years would you want that injury. So, knowing the location really helps a lot. Hopefully, this helps you understand tibial stress fractures a little bit better.
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