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A complete guide of tibia and fibula stress injuries

Updated: Jun 16, 2021

We will talk about:

  • Anatomy of the lower leg (between knee and ankle)

  • Stress injuries in the lower leg (between knee and ankle)

  • Diagnosis

  • Contributing/risk factors

  • Treatment

Let's get start:

Section 1 Anatomy of the lower leg:

  • Bone - tibia and fibula

  • Compartments - anterior (front), lateral (outside), posterior (backside)

  • Muscles - and their functions

Lower leg bones - tibia and fibula:


The tibia, also known as the shin bone, is the 2nd biggest bone in our body behind the femur (thigh bone), bearing our body weight. Its upper part is attached to the femur to form the knee joint, and the lower part attaches to the talus (ankle bone) to form the ankle joint. The tibia is located in the anteromedial (front and inside), closer to the body's central line than the fibula.


The slender fibula, also known as calf bone, plays minimal weight-bearing function; it lies posterolateral (back and outside) of the tibia. At the proximal end is the head of fibula attaching to the tibia. The fibula connects to the talus (ankle bone) at the distal end, forming the ankle joint. Fibula serves mainly for muscle attachment and provides stability to the ankle joint.

The tibia and fibula bodies are connected by an interosseous membrane, which is a strong oblique fiber.

Anatomy including tibia, fibula, lower leg muscles
Anatomy of lower leg

Bone anatomy of long bone, including periosteum, compact bone, spongy bone, bone marrow and medullary cavity

Tibia and fibula structure:

Bone tibia and fibula are classified as long bones with their outer surface covered by the periosteum. Underneath the periosteum is the outer shell of the long bone called the compact bone/cortical bone.

The cortical bone functions to support our body/protect internal organs/act as levers for movement/store and release bone chemicals. Beneath the cortical bone is the deeper layer of cancellous bone (spongy bone), which contains the medullary cavity and bone marrow.

Lower leg compartments

The lower leg is divided into 3 compartments by the intermuscular septa (fibrous tissue sheets) and the interosseous membrane:

  • Anterior (front) compartment

  • Lateral (outside) compartment

  • Posterior (backside): further divided into the deep and superficial compartments

Muscles in each compartment and their functions:

Lower leg anterior (front) compartment and muscles: Tibialis anterior, Extensor digitorum longus, Extensor hallucis longus, and Fibularis tertius
Lower leg Anterior (front) compartment
Lower leg lateral (outside) compartment and muscles: Fibularis longus, Fibularis brevis
Lower leg lateral (outside) compartment
Lower leg posterior (backside) superficial compartment and muscles: Gastrocnemius, Soleus, Plantaris
Lower leg posterior (backside) superficial compartment
Lower leg posterior (backside) deep compartment and muscles: Popliteus, Flexor digitorum longusFlexor hallucis longus, Tibialis posterior
Lower leg posterior (backside) deep compartment

Section 2: Stress injuries - stress syndrome, stress reaction, and stress fracture in the lower leg

  • Medial tibial stress syndrome

  • Stress reaction

  • Stress fracture

  • Characteristics in lower extremities stress fracture.

  • High-risk Vs. low-risk stress fracture

  • Magnetic Resonance Imaging (MRI) classification of stress injuries

Medial stress syndrome, stress reaction, and stress fractures are terms that we frequently encounter when we talk about stress injuries. It's worth spending some time knowing each of the terms and how they relate to each other. We can better understand how to prevent the injuries and figure out what treatments are beneficial to the condition.

What is medial tibial stress syndrome (MTSS)?

Medial tibial stress syndrome also known as shin splints, pain is located along the lower and inner leg shin area.

Medial tibial stress syndrome (MTSS), also known as shin splints, is a common lower limb exertional injury. It happens when our body is unable to heal well under repetitive muscle contraction and tibia strain. MTSS involves injuries such as tendinopathy and periostitis.

Tendinopathy: tendinosis (collagen breaking down of a tendon)

What is tendinopathy? It is the collagen breaking down of a tendon.

Periostitis: inflammation of the periosteum (a membrane covering the bone). Periostitis in MTSS usually occurs together with cortical bone microtrauma.

What is periostitis? Inflammation of the periosteum, the membrane that cover the bone

Which muscles are responsible for medial tibial stress syndrome (MISS)?

With the current scientific evidence, we can hardly accuse any particular muscle guilty of causing MTSS. Different theories are proposing the exact cause of MTSS, with no one being proven. Example of the approaches are:

  1. Soleus and Flexor Digitorum Longus, originating from the tibia's posteromedial (back and inside) border, are highly correlated with the MTSS injury. In particular, Soleus, which induces a traction longitudinal periostitis at the tibia.

  2. Gastrocnemius and Soleus muscles' contraction exerts a bending force in the tibia during the push-off phase of running.

  3. Gastrocnemius and Soleus plus the deep Flexor Digitorum Longus muscles' contraction.

Will medial tibial stress syndrome (MTSS) periostitis eventually crack the bone?

It is no doubt that the majority of MTSS periostitis is associated with cortical bone microtrauma*. Some researchers proposed that MTSS periostitis will eventually break the bone. However, some scientists argue that not all stress fractures developed from MTSS periostitis. They suggest that MTSS and stress fracture share some common risk factors, injury site, and etiology but are different in the injury development.

*22 out of 35 patients with MTSS have bone changes in the biopsy.

No matter MTSS and stress fracture are within the same spectrum of pathology. It is suggested that with early detection and intervention of stress syndrome, a fracture can be prevented.

What is a stress reaction?

The term stress reaction refers to the bone adapting to the pressure adding to it. During endurance activities such as running, muscles continue to increase in strength and exerting force on the bone. The bone is an ever-adapting structure. However, it adapts less rapidly than muscles. Muscles and tendons could adapt within weeks, whereas bone required months to catch up.

What is a stress fracture?

When the bone fails to adapt to stress, a condition called "microfractures" or "pre-stress fracture" will result; it will heal if stress factors are removed; if not, a clear fracture line could result. Stress fractures occur when the stress-induced microfracture exceeds the bone repaired rate, or people said bone resorption is faster than bone formation.

Bone remodeling is the process of breaking down old bone cell (Bone resorption) and forming new bone cell (Bone formation)

Bone resorption is when osteoclasts (demolisher bone cells) break down the bone tissues, releasing minerals (calcium) into the blood.

Bone formation/ossification is forming new bone tissue by the osteoblasts (builder bone cells).

From stress reaction to stress fracture

Stress reaction and stress fracture are a spectrum of conditions. One end is minor pain along the tibia/fibula bone that can elicit after exercises. A slight decrease in activity level or change of footwear can decrease the pain.

The other end of the spectrum is a stress fracture with severe pain that may make you unable to continue the sports activity. You may also feel pain at any other time, including daily ambulation or during rest.

In between the two extremes is a variation of symptoms. It could be a recurrence of pain when the activity intensity hits a certain level. Over a while (varies from months to years), if the activity level remains the same, there may be some structural change at the cortical bone, such as increased thickness.

Stress reaction and stress fracture are a spectrum of conditions. It range from minor pain after exercise to stress fracture of bone.

Characteristics in lower extremities stress fracture:

  • Stress fractures can occur in any bone.

  • Lower extremities account for 80% to 90 % of the total stress fracture.

  • Injury locations such as the pelvis, femur, tibia, fibula, or metatarsals.

  • Commonly occurs in individuals who participate in endurance and high-load activities such as running/hill-running/marching/dancing.


  • The most common lower extremities stress fracture, which accounts for 23.6%.

Statistics in lower extremities stress fracture, including tibia, fibula, navicular, and metatarsals
  • The majority are low risk and located posteromedially.

  • Commonly seen in athletics, military personnel, and recreational sports participants (3%-35%).

  • Anterior tibial stress fractures are less common yet considered high risk due to the high incidence of nonunion.


  • Occur around 7%-12%.

  • Pain is commonly localized to the lower fibula (7cm to 10 cm above or proximal to lateral malleolus)

  • Fibula does not play many weight-bearing roles; it is suggested that muscle imbalance is one factor that leads to a stress fracture.

High risk Vs. Low-risk stress fracture

A stress fracture can classify into high and low risk with different characteristics as follow:

Area and classification in high risk and low risk stress fractures.
Example of average return to participation timelines of high risk and low risk stress fractures.

Using Magnetic Resonance Imaging (MRI), stress injuries can classify into different level according to severity:

Magnetic resonance Imaging (MRI) classification of stress fractures to 4 level

Section 3: Diagnosis of the lower leg stress injuries

  • History

  • Clinical examination

  • Imaging

If you suspect you are suffering from lower leg stress injuries, always consult medical advice for a proper diagnosis. It is important to differentiate other lower extremity injuries/exertional pain such as compartment syndrome, muscle tears, fascial defects, venous thrombosis, artery/nerve entrapment, infection, or tumor from stress fractures.


Exercise routine:

A thorough understanding of sports activity routine is required to understand the situation, e.g.:

  • Exercise intensity

  • Frequency

  • Duration

  • Pace

  • Training terrain

  • Footwear

  • Any recent change in training routine: A drastic increase in training intensity or increased repetitive exercises without adequate rest is prone to stress injuries.

The behavior of pain:

  • Pain location: vague or localized pain

  • Pain intensity

  • Pain frequency

  • Pain duration

  • Onset and ceasing of pain

  • With or without resting pain

  • Refer pain, e.g., a proximal tibia stress fracture may refer to pain in the knee.

General health conditions, e.g.:

  • Nutritional disorder

  • Hormonal disorder

  • Sleeping disorder

  • Drinking/smoking habitats

Clinical examination:

General sign and symptoms of stress fracture in lower limbs:

  • local tenderness on injury site (65.9%-100%)

  • Local edema on injury site (18%-44%)

  • Pain during ambulation (81%)

Specific sign and symptoms of medial tibial stress syndrome:

  • Vague pain along the middle-lower tibia

  • Without edema

Specific sign and symptoms for tibia:

  • Pain during weight-bearing activities on the tibia shaft

  • pain with percussion.

Specific sign and symptoms for fibula:

  • Localized pain in fibula near/slightly above the ankle bone.

Core, pelvis, and leg muscles examination for:

  • Muscle weakness

  • Muscle tightness

  • Dysfunction

Special test /function test:

Hop test:

Single leg hopping that produces localized pain in patients with stress fractures can be used as functional diagnostic tests. However, its accuracy needs further validation. A pain provoke single-leg hop test is a common finding in people who developed stress fractures (70%-100%) as well as other stress syndromes (45.6%)

Tuning fork test (for stress fracture):

Apply a tuning fork to the injury site to provoke localized pain. This test needs further validation (one research reported a 75% sensitivity and 67% specificity)

Sensitivity: the proportion of positives that are correctly identified

Specificity: the proportion of negatives that are correctly identified


Imaging alone cannot be used as the only tool to diagnose stress injuries; they have to be used in conjunction with a thorough history and clinical examination.

Plain radiography: X-ray

Usually, an x-ray is the first imaging modality to consider due to its low cost and widely available, however, with poor sensitivity of about 10% in the acute stage. X-ray provides information about fracture line, periosteal bone formation, and cortical margin after 2 -3 weeks of symptoms. Its sensitivity increased to 30%-70% after 3 weeks as it takes time for the cortical irregularities and periosteal reactions to become evident.

After an initial x-ray with a negative result of a stress fracture and without the urgency of speedy diagnosis. With the caution that the diagnosis is provisional and exercises intensity should reduce/avoid stress. Another X-ray can be repeated after 2-3 weeks.

Computer tomography (CT)

Regularly used for bone pathology. However, CT is not preferred due to its higher radiation exposure and lower sensitivity.

Bone scan/ bone scintigram

Highly sensitive (74%-100%) but seldom used to diagnose stress fracture due to high radiation exposure. The increased bone activity resulting in the bone scan may indicate focal infection/tumors.

Magnetic resonance imaging (MRI)

Higher cost and less readily available compared to X-ray. MRI is equally or highly as sensitive as bone scintigram. Currently used as a confirmation test and is the next imaging technique considered if X-ray showed negative results. The advantage of MRI is its ability to display images of soft tissue, bone edema, and reactive bone remodeling (an early sign of stress fracture). Also, MRI has no radiation exposure.


Becoming more widely available. Pilot studies showed a sensitivity of 83.3% and a specificity of 75%. Its advantages are low cost and no radiation exposure.

Steps of using imaging to diagnose stress injuries:

Since the first onset of pain during exercises, the following steps can be employed by the medical team for the diagnosis of stress injuries:

Using X-ray, MRI or bone scan as diagnosis tools for stress injuries

Section 4 Contributing/risk factors to lower leg stress injuries:

  • Biological factors

  • Activity factors

  • Biomechanics/musculoskeletal factors

Biological factors increasing the risk of stress injuries:

  • Gender: Female 1.5-3.5 times increased risk for progression to stress fractures in the posteromedial tibia; female athlete triad (amenorrhea/osteoporosis/eating disorder), menstrual irregularities.

  • Maturity: immature bone when growth is not complete and bone mineral density is low.

  • Nutritional deficiencies: Such as calcium/25 hydroxyvitamin D and/or eating disorder.

  • Smoking

  • Consuming more than 10 alcoholic drinks per week.

  • Medication-induced deficiencies: such as antacids/steroids/antidepressants

  • Radiation

  • Imbalanced hormones

  • Sleep deprivation

  • Collagen anomalies

Activity factors that increase the risk of stress injuries:

  • Type of activity: Common in endurance or ballistic sports such as distance running/marching/basketball/football/dancing. Stress injuries account for 10% of total sports injuries, of which 30% occur in runners (20% incidence in track and field athletes).

  • Activity level: Sudden increase in running mileages without adequate rest, which means training is too much and/or too fast.

  • Equipment: Such as wearing shoes that wear and tear too much or without proper support.