Emerg Radiol DOI 10.1007/s10140-013-1181-1
ORIGINAL ARTICLE
Tibial stress phenomena and fractures: imaging evaluation Leonard E. Swischuk & Siddharth P. Jadhav
Received: 26 September 2013 / Accepted: 17 November 2013 # Am Soc Emergency Radiol 2013
Abstract This study aims to evaluate the various imaging modalities used to diagnose tibial stress–fractures/phenomena and determine which of these are most useful and definitive. The plain film, computed tomography (CT), magnetic resonance (MR), and nuclear medicine findings in a 20-patient cohort, ranging from ages 10 to 21 years with an average of 16 years, were reviewed. The male to female ratio was recorded as was the incidence of right or left, or bilateral extremity involvement. Thereafter, each imaging modality was evaluated for positive findings. Twelve of the patients had pretibial swelling on plain films, 10 a thickened cortex, to a visible fracture on plain films and 13 had increased short-tau inversion recovery (STIR) signal in the post tibial (marrow) and pretibial (subperiosteum) areas on MR imaging. No CT studies were performed. One positive nuclear medicine study was available. Although there are a number of imaging modalities which can be used to evaluate the tibial stress/fracture phenomena problem, it would appear that plain films and MR studies are most useful. If plain films do not show a fracture and further information is required, an MR study is most appropriate. Keywords Fractures . Stress . Tibia
growing evidence to support the spectrum of growing pains, shin splints, and overt stress fractures under the umbrella of the anteromedial tibial syndrome. There are a variety of imaging findings which can be helpful in identifying this syndrome, but some maybe more useful than others. Our study was designed to determine which of these imaging modalities was most efficient and direct at accomplishing the diagnosis of the tibial stress/fracture syndrome.
Methods The plain film, magnetic resonance (MR), and nuclear medicine findings in a 20-patient cohort, ranging from ages 10 to 21 years with an average of 16 years, were reviewed. The male to female ratio was recorded as was the incidence of right or left, or bilateral extremity involvement. In addition to any fractures seen, thickening of the anterior tibial cortex, and pretibial edema were evaluated on plain films. On the MR studies in addition to any fractures seen, the marrow and pre/peritibial soft tissue signal was evaluated on T1, T2, and short-tau inversion recovery (STIR) images. In the one nuclear medicine study, standard observation of increased nuclear activity was documented.
Introduction With the advent of modern imaging, stress phenomena/fractures are more readily identified in the lower extremity. These fractures most commonly occur in the tibia, and in this regard, there is This is from the Departments of Radiology, the University of Texas Medical Branch, Galveston, TX, USA and Texas Children’s Hospital, Houston, TX, USA. L. E. Swischuk (*) The University of Texas Medical Branch, Galveston, TX, USA e-mail: [email protected] S. P. Jadhav Department of Radiology, Texas Children’s Hospital, Houston, TX, USA
Results Results of this study are presented in Table 1.
Discussion With the advent of MR imaging, the pathophysiology and eventual outcome of the various stress phenomena involving the tibia has come to be greater understood. In this regard, although a variety of etiologic possibilities have been proposed in the past, it is now becoming more and more apparent that the tibial stress syndrome is one where there is excessive
Emerg Radiol Table 1 Patients profile Number of patients, 20 Male/M/F ratio, 6/14
Ages 10–21
Number of bilateral pain, 3 Anterior tibia (16 patients, 3 bilateral; total tibias, 19) Pretibial swelling plain films 12 Thick cortex tibia plain films 6 Periosteal layering 2 Fracture plain films 2 Nuclear medicine positive scan 1 MRI increased STIR signal, 9 pretibial (subperiosteal) MRI increased STIR signal, 9 marrow Posterior tibia (4 patients 4 tibias) Thick focal cortex healing fracture 4 plain films MRI increased STIR signal, 4 posterior–paratibial (subperiosteal) MRI increased STIR signal, 4 marrow
Mean age, 16 Total number of tibias, 23
and repetitive stress on the tibia with resultant microfractures, periosteal irritation, and associated marrow and paratibial soft tissue inflammation and edema (1). If this entire sequence of events is controlled by normal homeostatic mechanisms (i.e., bone insult–bone resorption–bone replacement–healing), only a thick cortex is seen (Fig. 1a). What this infers is that the homeostatic forces are in balance, and in favor of healing and rebuilding the cortex in the areas of stress. If this phenomenon is not controlled, and if it is surpassed, then the balance of stress and healing is reversed (2), with eventual fracturing (Fig. 1b). At the same time, and all the while, the periosteum is irritated by the microfractures (3, 4) resulting in reactive inflammation and edema of the periosteum, often only demonstrated with nuclear medicine or more currently MRI imaging (Fig. 2). Tibial stress phenomena/fractures occur most commonly over the upper anteromedial tibial cortex and hence the term medial, or anteromedial tibial syndrome (5, 6). Within this syndrome, there is a spectrum of findings ranging from nothing more than pain (growing pains and shin splints), through cortical and pretibial soft tissue swelling, to frank fracturing (7–10). Tibial stress also can occur over the lateral aspect of the tibia and over the lower third of the tibia (7) but the anteromedial location is most common. In addition, vertical stress fractures occasionally can occur (11) and with total reversal of forces, one can see stress fractures in the upper posterior tibia. With the upper anteromedial tibial stress syndrome, the involved forces are axial loading, hyperextension/
Fig. 1 Plain films: bony changes. a In this patient, only focal thickening of the anterior cortex (arrows) is seen. b In this patient, in addition to such thickening, an actual transverse stress fracture (arrowhead) is seen
Fig. 2 Value of MR imaging. a In this patient with anterior pain (shin splints), the radiograph is basically normal. There may be a little pretibial soft tissue swelling but it is borderline. b MR, axial STIR image demonstrates hyperintense signal over the anterior tibia (arrow). There also is abnormal hyperintensity in the marrow
Emerg Radiol Fig. 3 Soft tissue findings: plain film. a In this patient, note the marked thickening of the deep soft tissues (arrows) anterior to the tibia. b In this patient, soft tissue thickening (arrow) is present but not readily apparent. c Comparative view of the other side however, enables one to make a more definitive assessment of the thickened soft tissues in b
compressive forces exerted on the anterior tibial cortex. In our study, it was interesting that on plain films, 12 of 19 tibias (63 %) showed swelling of the deep soft tissues over the anterior tibia (Fig. 3a). This finding is difficult to assess, but if positioning is correct and comparative views are obtained, the finding is easier to evaluate (Fig. 3b, c). The finding probably represents a combination of reactive periosteal inflammation and inflammation of the overlying subcutaneous soft tissues. Two (2) patients demonstrated periosteal reaction and overt transverse anterior tibial stress fractures (see Fig. 1b). In terms of the plain film findings of pretibial edema and tibial cortical thickening, both are difficult to measure with
Fig. 4 Upper posterior tibial stress fracture. a Plain films demonstrate focal cortical thickening in the upper posterior tibia (arrow). b Sagittal MR image demonstrates hyperintense signal posterior to the tibia (arrows) and signal in the marrow (M). c Axial STIR image demonstrates increased signal (arrows) over the posterior tibia. Also note the focal cortical thickening. Increased signal also is present in the marrow (M)
confidence unless comparative views are obtained. However, they are not intended to be diagnostic, only suggestive, and then further imaging could be undertaken. With posterior, upper tibial stress fractures, hyperextension forces also are at play. In fact, this fracture is very similar to the Toddler II fracture seen in infants (12). In infants, this stress fracture usually is associated with anterior tibial buckling and a variably visible posterior diastatic upper tibial fracture. In older children and adolescents, one usually sees only reactive periosteal bone formation in the upper posterior tibia where thick callus is the hallmark of this condition (Fig. 4a). An actual fracture line usually is not seen but the configuration and location of this fracture is basically
Emerg Radiol Fig. 5 Tibial stress phenomena: value of nuclear medicine imaging. a This patient had pain in the left lower extremity. The plain films are basically normal except for some suggestion of cortical thickening. b Early-phase nuclear medicine study demonstrates increased activity in both anterior tibias (arrows). c Delayed image demonstrates fixed uptake in the left tibia (arrow) consistent with the patient’s symptoms
pathognomonic. With CT imaging, the thickened cortex also is readily demonstrable; with MR imaging, hyperintense increased soft tissue signal on STIR images over the fracture site is common. In more advanced cases, abnormal marrow signal also is seen (Fig. 4b, c). Generally however, MR imaging is not required as the plain film findings are very definitive. Nuclear medicine studies in the past were key in identifying the tibial stress fracture/phenomenon if plain film findings were not diagnostic. In such cases, increased tracer activity is seen over the involved tibia but the findings are nonspecific (Fig. 5). Currently, this imaging modality has been, for the most part, supplanted by MR imaging. Similarly, CT, which always has been useful in detecting these fractures, and still remains useful, also generally is yielding to MR imaging. In addition, CT utilizes ionization radiation while MR does not. MR imagining (13–15) also has the advantage of being able to provide information regarding the bone marrow, the bone, the periosteum, and the overlying soft tissues. Fredericson et al. (16) has proposed an MRI grading system for stress injuries and in this regard it is important to distinguish stress reaction from a stress fracture since the latter needs a longer period of activity restriction. With MR imaging, the most minimal findings usually consist of a thin layer of hyperintense signal (periostitis) over the anterior medial tibia, best seen on STIR images. In more
advanced cases, the zone of hyperintensity becomes wider and more extensive and associated abnormal marrow signal is seen. All of these findings also are seen, to some extent on T2-weighted imaging but STIR imaging is best. Gadolinium contrast is usually not required. A spectrum of the changes seen on the STIR images is presented in Fig. 6. These findings although suggested to be nonspecific (17) are very definitive if the clinical history and physical findings point towards the possible diagnosis of a tibial stress fracture/phenomena. Positive MR studies were present in 13 of 13 (100 %) of our patients who received an MR study.
Fig. 6 MR STIR axial imaging: spectrum of findings. a In this patient, there is minimal hyperintense signal over the anterior tibia (arrow) and some hyperintensity along the endosteal surface. b In this patient, increased signal over the anterior and medial tibia is much more
pronounced. There is also abnormal high signal in the marrow. c In this patient, there is extensive peritibial edema extending into the adjacent muscles. In addition, there is marked increased signal of the marrow. Also note the abnormal intracortical signal
Conclusion Tibial stress fractures/phenomena are very common and are becoming more common as young people take on more physical activity. The entire spectrum of clinical and imaging findings is best considered under the broad umbrella of the anteromedial tibial syndrome. Plain films are very useful in initially detecting the abnormities in these patients and often are totally diagnostic. However, MR imaging is becoming more and more important, especially in those patients where diagnosis is not fully accomplished with plain films and in those patients with an athletic
Emerg Radiol
career in the picture. Both CT and nuclear medicine studies are more and more fading into the background.
Conflict of Interest The authors do not have any items to disclose.
References 1. Tweed J, Avil S, Campbell J, Barnes M (2008) Etiologic factors in the development of medial tibial stress syndrome: a review of the literature. J Am Podiatr Med Assoc 98(2):107–111 2. Li G, Zhang S, Chen G, Chen G, Chen H, Wang A (1985) Radiographic and histologic analysis of stress fracture in rabbit tibias. Amer J Sports Med 13(5):285–294 3. Uthoff HK, Jawoski ZFG (1985) Periosteal stress-induced reactions resembling stress fractures. A radiologic and histologic study in dogs. Clin Orthop Relat Res 199:284–291 4. Michael RH, Holder LE (1985) The soleus syndrome. A cause of medial tibial stress(shin splints). Amer J of Sports Med 13(2):87–94 5. Puranen J (1974) The medial tibial syndrome: exercise ischaemia in the medial fascial compartment of the leg. J Bone Joint Surg 56B:712–715 6. Mubarak SJ, Gould RN, Lee YF, Schmidt DA, Hargens AR (1982) The medial tibial stress syndrome. A cause of shin splints. Amer J Sport Med 10(4):201–205 7. Slocum DB (1967) The shin splint syndrome: medical aspects and differential diagnosis. Am J Surg 114:875–881
8. Detmer DE (1986) Chronic shin splints. Classification and management of medial tibial stress syndrome. Sports Med 3: 436–446 9. Devas MB (1958) Stress fractures of the tibia in athletes or “shin soreness”. J Bone Joint 40B:227–239 10. Daffner R, Pavlov H (1992) Stress fractures: current concepts. AJR 159:245–252 11. Allen GJ (1988) Longitudinal stress fractures of the tibia: diagnosis with CT. Radiol 167:799–801 12. Swischuk SE, John SD, Tschoepe EJ (1999) Upper tibial hyperextension fractures in infants: another occult toddler’s fracture. Pediatr Radiol 29:6–9 13. Gaeta M, Minutoli F, Scribano E, Ascenti G, Vinci S, Bruschetta D, Magaudda L, Blandino A (2005) CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiol 235: L553–L561 14. Kijowski R, Choi J, Shinki D, Nunoz DelRio A, De Smet A (2012) Validation of MRI classification system for tibial stress injuries. AJR 198:878–884 15. Lee JK, Yao L (1988) Stress fractures: MR imaging. Radiol 169:217– 220 16. Fredericson M, Bergman AG, Hoffman KL, Dillingham MF (1995) Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 23:472–481 17. Horev G, Korenreich L, Ziv N, Grunebaum M (1990) The enigma of stress fractures in the pediatric age: clarification or confusion through the new imaging modalities. Pedi Radiol 20:469–471
ORIGINAL ARTICLE
Tibial stress phenomena and fractures: imaging evaluation Leonard E. Swischuk & Siddharth P. Jadhav
Received: 26 September 2013 / Accepted: 17 November 2013 # Am Soc Emergency Radiol 2013
Abstract This study aims to evaluate the various imaging modalities used to diagnose tibial stress–fractures/phenomena and determine which of these are most useful and definitive. The plain film, computed tomography (CT), magnetic resonance (MR), and nuclear medicine findings in a 20-patient cohort, ranging from ages 10 to 21 years with an average of 16 years, were reviewed. The male to female ratio was recorded as was the incidence of right or left, or bilateral extremity involvement. Thereafter, each imaging modality was evaluated for positive findings. Twelve of the patients had pretibial swelling on plain films, 10 a thickened cortex, to a visible fracture on plain films and 13 had increased short-tau inversion recovery (STIR) signal in the post tibial (marrow) and pretibial (subperiosteum) areas on MR imaging. No CT studies were performed. One positive nuclear medicine study was available. Although there are a number of imaging modalities which can be used to evaluate the tibial stress/fracture phenomena problem, it would appear that plain films and MR studies are most useful. If plain films do not show a fracture and further information is required, an MR study is most appropriate. Keywords Fractures . Stress . Tibia
growing evidence to support the spectrum of growing pains, shin splints, and overt stress fractures under the umbrella of the anteromedial tibial syndrome. There are a variety of imaging findings which can be helpful in identifying this syndrome, but some maybe more useful than others. Our study was designed to determine which of these imaging modalities was most efficient and direct at accomplishing the diagnosis of the tibial stress/fracture syndrome.
Methods The plain film, magnetic resonance (MR), and nuclear medicine findings in a 20-patient cohort, ranging from ages 10 to 21 years with an average of 16 years, were reviewed. The male to female ratio was recorded as was the incidence of right or left, or bilateral extremity involvement. In addition to any fractures seen, thickening of the anterior tibial cortex, and pretibial edema were evaluated on plain films. On the MR studies in addition to any fractures seen, the marrow and pre/peritibial soft tissue signal was evaluated on T1, T2, and short-tau inversion recovery (STIR) images. In the one nuclear medicine study, standard observation of increased nuclear activity was documented.
Introduction With the advent of modern imaging, stress phenomena/fractures are more readily identified in the lower extremity. These fractures most commonly occur in the tibia, and in this regard, there is This is from the Departments of Radiology, the University of Texas Medical Branch, Galveston, TX, USA and Texas Children’s Hospital, Houston, TX, USA. L. E. Swischuk (*) The University of Texas Medical Branch, Galveston, TX, USA e-mail: [email protected] S. P. Jadhav Department of Radiology, Texas Children’s Hospital, Houston, TX, USA
Results Results of this study are presented in Table 1.
Discussion With the advent of MR imaging, the pathophysiology and eventual outcome of the various stress phenomena involving the tibia has come to be greater understood. In this regard, although a variety of etiologic possibilities have been proposed in the past, it is now becoming more and more apparent that the tibial stress syndrome is one where there is excessive
Emerg Radiol Table 1 Patients profile Number of patients, 20 Male/M/F ratio, 6/14
Ages 10–21
Number of bilateral pain, 3 Anterior tibia (16 patients, 3 bilateral; total tibias, 19) Pretibial swelling plain films 12 Thick cortex tibia plain films 6 Periosteal layering 2 Fracture plain films 2 Nuclear medicine positive scan 1 MRI increased STIR signal, 9 pretibial (subperiosteal) MRI increased STIR signal, 9 marrow Posterior tibia (4 patients 4 tibias) Thick focal cortex healing fracture 4 plain films MRI increased STIR signal, 4 posterior–paratibial (subperiosteal) MRI increased STIR signal, 4 marrow
Mean age, 16 Total number of tibias, 23
and repetitive stress on the tibia with resultant microfractures, periosteal irritation, and associated marrow and paratibial soft tissue inflammation and edema (1). If this entire sequence of events is controlled by normal homeostatic mechanisms (i.e., bone insult–bone resorption–bone replacement–healing), only a thick cortex is seen (Fig. 1a). What this infers is that the homeostatic forces are in balance, and in favor of healing and rebuilding the cortex in the areas of stress. If this phenomenon is not controlled, and if it is surpassed, then the balance of stress and healing is reversed (2), with eventual fracturing (Fig. 1b). At the same time, and all the while, the periosteum is irritated by the microfractures (3, 4) resulting in reactive inflammation and edema of the periosteum, often only demonstrated with nuclear medicine or more currently MRI imaging (Fig. 2). Tibial stress phenomena/fractures occur most commonly over the upper anteromedial tibial cortex and hence the term medial, or anteromedial tibial syndrome (5, 6). Within this syndrome, there is a spectrum of findings ranging from nothing more than pain (growing pains and shin splints), through cortical and pretibial soft tissue swelling, to frank fracturing (7–10). Tibial stress also can occur over the lateral aspect of the tibia and over the lower third of the tibia (7) but the anteromedial location is most common. In addition, vertical stress fractures occasionally can occur (11) and with total reversal of forces, one can see stress fractures in the upper posterior tibia. With the upper anteromedial tibial stress syndrome, the involved forces are axial loading, hyperextension/
Fig. 1 Plain films: bony changes. a In this patient, only focal thickening of the anterior cortex (arrows) is seen. b In this patient, in addition to such thickening, an actual transverse stress fracture (arrowhead) is seen
Fig. 2 Value of MR imaging. a In this patient with anterior pain (shin splints), the radiograph is basically normal. There may be a little pretibial soft tissue swelling but it is borderline. b MR, axial STIR image demonstrates hyperintense signal over the anterior tibia (arrow). There also is abnormal hyperintensity in the marrow
Emerg Radiol Fig. 3 Soft tissue findings: plain film. a In this patient, note the marked thickening of the deep soft tissues (arrows) anterior to the tibia. b In this patient, soft tissue thickening (arrow) is present but not readily apparent. c Comparative view of the other side however, enables one to make a more definitive assessment of the thickened soft tissues in b
compressive forces exerted on the anterior tibial cortex. In our study, it was interesting that on plain films, 12 of 19 tibias (63 %) showed swelling of the deep soft tissues over the anterior tibia (Fig. 3a). This finding is difficult to assess, but if positioning is correct and comparative views are obtained, the finding is easier to evaluate (Fig. 3b, c). The finding probably represents a combination of reactive periosteal inflammation and inflammation of the overlying subcutaneous soft tissues. Two (2) patients demonstrated periosteal reaction and overt transverse anterior tibial stress fractures (see Fig. 1b). In terms of the plain film findings of pretibial edema and tibial cortical thickening, both are difficult to measure with
Fig. 4 Upper posterior tibial stress fracture. a Plain films demonstrate focal cortical thickening in the upper posterior tibia (arrow). b Sagittal MR image demonstrates hyperintense signal posterior to the tibia (arrows) and signal in the marrow (M). c Axial STIR image demonstrates increased signal (arrows) over the posterior tibia. Also note the focal cortical thickening. Increased signal also is present in the marrow (M)
confidence unless comparative views are obtained. However, they are not intended to be diagnostic, only suggestive, and then further imaging could be undertaken. With posterior, upper tibial stress fractures, hyperextension forces also are at play. In fact, this fracture is very similar to the Toddler II fracture seen in infants (12). In infants, this stress fracture usually is associated with anterior tibial buckling and a variably visible posterior diastatic upper tibial fracture. In older children and adolescents, one usually sees only reactive periosteal bone formation in the upper posterior tibia where thick callus is the hallmark of this condition (Fig. 4a). An actual fracture line usually is not seen but the configuration and location of this fracture is basically
Emerg Radiol Fig. 5 Tibial stress phenomena: value of nuclear medicine imaging. a This patient had pain in the left lower extremity. The plain films are basically normal except for some suggestion of cortical thickening. b Early-phase nuclear medicine study demonstrates increased activity in both anterior tibias (arrows). c Delayed image demonstrates fixed uptake in the left tibia (arrow) consistent with the patient’s symptoms
pathognomonic. With CT imaging, the thickened cortex also is readily demonstrable; with MR imaging, hyperintense increased soft tissue signal on STIR images over the fracture site is common. In more advanced cases, abnormal marrow signal also is seen (Fig. 4b, c). Generally however, MR imaging is not required as the plain film findings are very definitive. Nuclear medicine studies in the past were key in identifying the tibial stress fracture/phenomenon if plain film findings were not diagnostic. In such cases, increased tracer activity is seen over the involved tibia but the findings are nonspecific (Fig. 5). Currently, this imaging modality has been, for the most part, supplanted by MR imaging. Similarly, CT, which always has been useful in detecting these fractures, and still remains useful, also generally is yielding to MR imaging. In addition, CT utilizes ionization radiation while MR does not. MR imagining (13–15) also has the advantage of being able to provide information regarding the bone marrow, the bone, the periosteum, and the overlying soft tissues. Fredericson et al. (16) has proposed an MRI grading system for stress injuries and in this regard it is important to distinguish stress reaction from a stress fracture since the latter needs a longer period of activity restriction. With MR imaging, the most minimal findings usually consist of a thin layer of hyperintense signal (periostitis) over the anterior medial tibia, best seen on STIR images. In more
advanced cases, the zone of hyperintensity becomes wider and more extensive and associated abnormal marrow signal is seen. All of these findings also are seen, to some extent on T2-weighted imaging but STIR imaging is best. Gadolinium contrast is usually not required. A spectrum of the changes seen on the STIR images is presented in Fig. 6. These findings although suggested to be nonspecific (17) are very definitive if the clinical history and physical findings point towards the possible diagnosis of a tibial stress fracture/phenomena. Positive MR studies were present in 13 of 13 (100 %) of our patients who received an MR study.
Fig. 6 MR STIR axial imaging: spectrum of findings. a In this patient, there is minimal hyperintense signal over the anterior tibia (arrow) and some hyperintensity along the endosteal surface. b In this patient, increased signal over the anterior and medial tibia is much more
pronounced. There is also abnormal high signal in the marrow. c In this patient, there is extensive peritibial edema extending into the adjacent muscles. In addition, there is marked increased signal of the marrow. Also note the abnormal intracortical signal
Conclusion Tibial stress fractures/phenomena are very common and are becoming more common as young people take on more physical activity. The entire spectrum of clinical and imaging findings is best considered under the broad umbrella of the anteromedial tibial syndrome. Plain films are very useful in initially detecting the abnormities in these patients and often are totally diagnostic. However, MR imaging is becoming more and more important, especially in those patients where diagnosis is not fully accomplished with plain films and in those patients with an athletic
Emerg Radiol
career in the picture. Both CT and nuclear medicine studies are more and more fading into the background.
Conflict of Interest The authors do not have any items to disclose.
References 1. Tweed J, Avil S, Campbell J, Barnes M (2008) Etiologic factors in the development of medial tibial stress syndrome: a review of the literature. J Am Podiatr Med Assoc 98(2):107–111 2. Li G, Zhang S, Chen G, Chen G, Chen H, Wang A (1985) Radiographic and histologic analysis of stress fracture in rabbit tibias. Amer J Sports Med 13(5):285–294 3. Uthoff HK, Jawoski ZFG (1985) Periosteal stress-induced reactions resembling stress fractures. A radiologic and histologic study in dogs. Clin Orthop Relat Res 199:284–291 4. Michael RH, Holder LE (1985) The soleus syndrome. A cause of medial tibial stress(shin splints). Amer J of Sports Med 13(2):87–94 5. Puranen J (1974) The medial tibial syndrome: exercise ischaemia in the medial fascial compartment of the leg. J Bone Joint Surg 56B:712–715 6. Mubarak SJ, Gould RN, Lee YF, Schmidt DA, Hargens AR (1982) The medial tibial stress syndrome. A cause of shin splints. Amer J Sport Med 10(4):201–205 7. Slocum DB (1967) The shin splint syndrome: medical aspects and differential diagnosis. Am J Surg 114:875–881
8. Detmer DE (1986) Chronic shin splints. Classification and management of medial tibial stress syndrome. Sports Med 3: 436–446 9. Devas MB (1958) Stress fractures of the tibia in athletes or “shin soreness”. J Bone Joint 40B:227–239 10. Daffner R, Pavlov H (1992) Stress fractures: current concepts. AJR 159:245–252 11. Allen GJ (1988) Longitudinal stress fractures of the tibia: diagnosis with CT. Radiol 167:799–801 12. Swischuk SE, John SD, Tschoepe EJ (1999) Upper tibial hyperextension fractures in infants: another occult toddler’s fracture. Pediatr Radiol 29:6–9 13. Gaeta M, Minutoli F, Scribano E, Ascenti G, Vinci S, Bruschetta D, Magaudda L, Blandino A (2005) CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiol 235: L553–L561 14. Kijowski R, Choi J, Shinki D, Nunoz DelRio A, De Smet A (2012) Validation of MRI classification system for tibial stress injuries. AJR 198:878–884 15. Lee JK, Yao L (1988) Stress fractures: MR imaging. Radiol 169:217– 220 16. Fredericson M, Bergman AG, Hoffman KL, Dillingham MF (1995) Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 23:472–481 17. Horev G, Korenreich L, Ziv N, Grunebaum M (1990) The enigma of stress fractures in the pediatric age: clarification or confusion through the new imaging modalities. Pedi Radiol 20:469–471
