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  • An overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures 
  • Epidemiology
    • commonly seen in runners and military recruits
    • seen after change in training routine
  • Mechanism
    • linear microfractures in trabecular bone from repetitive loading
  • Pathophysiology
    • callus formation
    • woven bone
    • endochondral bone formation
  • History
    • change in exercise routine
  • Symptoms
    • onset of symptoms often insidious
    • symptoms initially worse with running, then may develop symptoms with daily activities
  • Physical exam
    • pain directly over fracture
  • Radiographs
    • recommended views
      • AP and lateral
    • findings
      • lateral xray may show "dreaded black line" anteriorly indicating tension fracture from posterior muscle force 
      • endosteal thickening
      • periosteal reaction with cortical thickening
  • Technetium Tc 99m bone scan
    • findings
      • focal uptake in cortical and/or trabecular region
  • MRI
    • replacing bone scan for diagnosis and is most sensitive 
    • findings
      • marrow edema 
      • earliest findings on T2-weighted images 
        • periosteal high signal
      • T1-weighted images show linear zone of low signal
  • Nonoperative
    • activity restriction with protected weightbearing q q
      • indications
        • most cases
      • technique
        • avoids NSAIDs (slows bone healing)
        • consider bone stimulator
  • Operative
    • intramedullary tibial nailing q
      • indications
        •  if "dreaded black line" is present, especially if it violates the anterior cortex
          • fractures of anterior cortex of tibia have highest likelihood of delayed healing or non-union q

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