#840 What is periosteal elevation in tibial stress reaction? - DOC

#840 What is periosteal elevation in tibial stress reaction?

What is periosteal elevation in a stress fracture in a runner? Well, that’s what we’re talking about today on the Doc On The Run Podcast.



When you get a stress fracture, one of the earliest things that you can see on an X-ray or an MRI or a CT scan is a thing called periosteal elevation. You can even see this on ultrasound studies. So, since it’s one of the most common things that we can actually see, one of the earliest things we can see when you starting to get a stress fracture, I thought it might be useful to talk about it because most of the time when I see runners with this issue, and it’s a finding on their MRI, they have no idea what that means.

Let’s talk about it and this could apply basically to a tibial stress fracture, a tibial stress reaction, a metatarsal stress fracture, a metatarsal stress reaction, any of those things that you could get as a consequence of an overtraining injury when you’re running. So, what does it mean? Let’s talk about it.

Let’s use the tibia as the example. So, your tibia looks like this. You’ve got part down here that goes to your ankle, you have the part up here that’s under your knees, your femur is sitting on top of here. Your talus bone sitting under here, and you have your fibula on the other side.

So, what is the periosteum? Well, the periosteum is a very thin layer. of covering that is connected to the bone that’s sitting on the bone all the way down around the bone, the whole way. It’s right next to the bone. There’s no space between the bone and the periosteum. And in surgery, when we go in there and you have a fracture, we’re looking at the periosteum, the periosteum looks kind of like it’s a layer that covers the whole thing, but it looks kind of like strapping tape if you know what that is. So, strapping tape’s kind of clear and has these white sort of fibrous strands of material in it that make it super strong and the periosteum is very similar.

If you actually take a scalpel when you peel the periosteum off the bone looks like strapping tape but it goes all the way around the bone. So, what is periosteal elevation? Well, if you look at bone here, we basically make this exact same outline to keep things simple and you have periosteal elevation, it’s where the periosteum lifts away from the bone. So, the periosteum will be let’s say, and let’s say you got your tibial stress fracture about right here, that this is where it’s happening. And let’s just say it’s a stress reaction, it’s inflamed, it’s irritated, has excess fluid in there but it’s not actually cracked yet. And so that’s right here.

If you had periosteal elevation, instead of the periosteum being right next to the bone, what you would have is the periosteum would be right next to the bone there but where you’re getting that increased blood flow within the bone, it actually lifts away from the bone like that.

Sometimes, on an X-ray, you can see it. You’ll actually see a little shadow on the side of the bone right where you have developed a stress fracture and that’s periosteal elevation. It can be on an MRI, you can see where the periosteum is lifted away and there’s fluid in between the periosteum in the covering the bone. On ultrasound, when I see somebody at home who has a stress fracture, they’re freaked out, they’re worried, they don’t want to wait a couple of weeks for an MRI, I can actually see what we call a Hypoechoic line.

You basically have a dark place, it’s super dark because on the ultrasound, it’s really dark right there and creates a space between the periosteum and the bone because fluid transmits ultrasound waves very clearly and simply. So, the ultrasound waves go through, they reflect off of the bone that’s bright white, and it goes right through that little bubble of fluid where its pushed the periosteum off, you see this little dark shadow and that’s what periosteal lifting is. It means you have fluid in there and usually when you push on it because there’s a lot of nerve endings in the periosteum when you push on it, it hurts. If you push on one spot on the bone and it hurts right there, that may be because of the periosteal lifting and you might be able to see it on medical imaging.

If you want to learn more about stress fractures, come check out the stress fracture masterclass. It’s here I do a deep dive into all of the strategies and frameworks I use to treat injured runners with stress fractures and stress reactions who want to keep working out. You can come check it out at www.docontherun.com/stressfracturemasterclass. So, go sign up and I’ll see you inside.