How to Heal a Stress Fracture in Shin?

You have a stress fracture of the tibia (also known as a hairling fracture of the shin), and you have many questions about the required rest and healing time, treatment, and physical therapy? You’re also wondering how to prevent a recurrence?

I will answer all these questions based on my experience as a certified physiotherapist.

You will also see that I like to rely as much as possible on the results of clinical studies conducted on the subject and published in the international scientific literature (all references at the end of the article).

What are the symptoms of a stress fracture of the tibia?

The signs of a tibial stress fracture (also known as a hairline fracture) are:

• Pain in a specific area along the shin or over a significant portion of its length. A tibial stress fracture is usually painful. However, sometimes people may not immediately feel the pain or may never experience it. The pain worsens with activity and diminishes at rest.
• Swelling in the tibial region.
• Bruising (discoloration).
• Difficulties in walking or bearing weight on the affected leg.

These signs may not all be present.

Clinical tests are sometimes performed to further confirm the diagnosis:

• The tibial point tenderness test, where pressure is applied to the tibia on the practitioner’s knee (fulcrum test).
• Jumping test, where the person jumps, and the pain response is observed (hop test).

However, these tests are not always highly reliable.

Additional imaging examinations such as X-ray, ultrasound, CT scan, or bone scintigraphy are sometimes conducted to ensure a more accurate diagnosis. However, they are not routine.

These additional examinations may be considered, for example, if there is no improvement after 2 or 3 weeks of strict rest.

Source: Milgrom 2021.

Stress fracture or shin splints?

Shin splints refer to the inflammation of the membrane surrounding the bones, while a tibial stress fracture is a break in the tibia bone.

Shin splints are a common issue among runners, as well as people who engage in activities that involve significant walking, such as certain occupations.

Symptoms of shin splints

The symptoms of shin splints resemble those of a stress fracture:

• Tenderness along the tibia (and sometimes the fibula), typically in the lower two-thirds.
• Pain that may persist even at rest, without any pressure.
• Increased pain during physical activity.
• Swelling.

The intensity of the pain is not a reliable indicator. Severe pain can be associated with shin splints or tendonitis, while a stress fracture may cause minimal or no pain (Milgrom 2021).

Diagnosis of shin splint VS tibial stress fracture

Distinguishing between shin splints and a shin harline fracture can be accomplished by a sports physician or physiotherapist experienced in such injuries. This process is known as a differential diagnosis.

An initial assessment can be made based on the patient’s history, including the type, frequency, and intensity of recent physical exertion, as well as the presenting symptoms. Additional imaging examinations can be used to confirm the diagnosis if there is uncertainty.

However, such diagnostic imaging is not always necessary, as the treatment approach for shin splints and stress fractures follows similar principles: rest and gradual return to activity.

Diagnostic error?

If you have concerns that your shin splints may have been misdiagnosed, and you wished for further examinations, take comfort in the fact that the treatment approach for shin splints and stress fractures aligns closely.

In terms of frequency, shin splints are more common than tibial stress fractures. Although there are no precise figures for large sample sizes regarding tibial shin fractures, studies indicate that:

• Approximately 14 to 20% of runners experience shin splints at least once in their lifetime (McClure 2022). Shin splints can also be caused by factors such as obesity, metabolic diseases, and infections, so they can be present in individuals who do not engage in intense physical activities.
• Among a population of military personnel, 6 out of 1000 people had a tibial stress fracture over the course of a year, with 40% of them experiencing a stress fracture. It is the most common location for stress fractures, but still less frequent than shin splints (Waterman 2016).

As a personal anecdote, I discovered the profession of physiotherapy more than 10 years ago when I myself had shin splints. As a teenager heavily involved in athletics, I became familiar with this condition early on. Back then, the treatment from the physiotherapist involved applying the back of a small spoon along the shin and demonstrating hamstring stretches!

Tendonitis or stress fracture in the shint?

Tendonitis (or tendinopathy) is an inflammation of a tendon, which is the strong band of tissue that connects muscle to bone.

Tendonitis in the tibia is relatively rare, but it can occur if you engage in repetitive movements that put strain on the tendon of the posterior or anterior tibial muscle.

Common symptoms include:

• Pain
• Stiffness
• Weakness in the ankle and lower leg area.

However, in general, the pain of tendonitis can be clearly distinguished from the pain of a fracture. Tendonitis pain is typically localized lower on the tibia. Most importantly, it is particularly intense when contracting the anterior or posterior tibial muscles.

If necessary, imaging can help to confirm the diagnosis, such as an ultrasound, which can visualize soft tissues like tendons.

A healthcare professional experienced in diagnosing stress fractures, shin splints, and tendonitis can often make a differential diagnosis without additional examinations. However, it can be challenging for individuals to self-diagnose among these three conditions.

What causes a stress fracture of the tibia?

Stress fracture is a condition that occurs in the vast majority of cases among people who engage in running.

They are also referred to as stress fractures because they are caused by mechanical stress. Not stress in the mental sense, but mechanical stress.

Mechanical stress refers to the fact that there is a significant and repeated load on your bone. Over time, the bone is deformed by microfissures because the load is applied before the bone has had enough time to repair and remodel itself.

Some people have lower bone density than others (often due to genetic predispositions) and are at higher risk.

Athletes, especially runners and jumpers, are particularly at risk of developing stress fractures because they frequently subject their tibia to intense strain by running on hard surfaces and engaging in frequent jumping.

Activities involving repetitive movements, such as dance, alpine skiing, and racket sports, can also cause stress fractures. Similarly, having osteoporosis can contribute to their occurrence. (Bolthouse)

However, stress fractures can occur at any age and in people who do not have known risk factors (who do not engage in sports).

In runners, stress fractures typically occur:

• When starting running and running too fast, too long, too frequently, or too intensely.
• When returning to running after a period of inactivity or reduced activity and pushing too hard.
• Due to improper footwear.
• When increasing training load in running too quickly.
• When inadequate nutrition and rest are present.
• When running more than 64 kilometers per week. (Bolthouse)

Of course, as is always the case in medicine, there are significant differences and variations between individuals based on genetic factors. Some people can handle the increased load more easily, while others cannot.

Some studies aim to investigate whether there are differences in running biomechanics between individuals who experience this type of injury and those who do not. Apparently, there are no significant differences. (Milner 2022)

Stress fractures in the shin often occur when there is a rapid, frequent, intense increase in loads and stresses on the lower limbs.

Can you still walk with a stress fracture in your shin?

In the first few weeks following the diagnosis of a stress fracture in the tibia, walking is limited.

It is possible to walk with crutches, but with significantly reduced weight-bearing on the fractured leg:

• Either by not placing the foot on the ground at all (hopping/walking on one foot).
• Or by using a “touch-down” weight-bearing method, where the foot lightly touches the ground while most of the weight is supported by the crutches.

Why limit walking in this way? To:

• Reduce pain.
• Facilitate the consolidation and healing process.

How to treat a stress fracture in shin?

The treatment will depend on the severity of the fracture (grade 1, 2, 3, 4), your goals, and the practices of the healthcare team you turn to. The general objectives of the treatment are to:

• Protect the injured bone to enable healing.
• Alleviate pain.
• Restore joint function.

Here are the main treatments commonly used for stress fractures in the tibia:

• Rest and immobilization: This is the most important step in treating a stress fracture in the tibia. It is crucial to limit activities that could worsen the bone damage, such as walking, running, and jumping. Often, a splint or walking boot (see on Amazon) is prescribed to immobilize the leg for a specified period of rest determined by your doctor. Typically, 1 to 6 weeks of strict rest are recommended, sometimes longer, especially for fractures located at the anterior edge of the tibia. This is followed by several weeks of low-impact activities, including gentle walking.
• Physical therapy: During the consolidation phase, physical therapy may not be prescribed. Once the bone has consolidated, therapy sessions are often recommended. The goal is to gradually regain muscle strength and desired training intensity while minimizing the risk of recurrence or other injuries.
• Physiotherapy and pain management: Different devices may be used by physical therapists or at home to relieve pain (without accelerating healing) or reduce swelling during the consolidation phase (TENS, cryotherapy, ultrasound therapy, shockwave therapy, compression boots, etc.). However, their superiority over a placebo has not been demonstrated.
• Medications: Your doctor may prescribe medications to alleviate pain, but nothing to “speed up healing!”
• Surgery: In rare cases where the fracture does not heal properly with conservative treatments (described above), surgery may be necessary to realign the bone fragments and maintain proper bone position during healing. However, surgery is not the first-line approach.

Generally, follow-up examinations will be conducted by the diagnosing and treating physician. Based on these exams, a gradual resumption of weight-bearing can be initiated if the results are favorable.

Rest followed by a progressive and controlled return to activity based on the patient’s symptoms is the modern approach to managing tibial stress fractures. (Jatsy 2021)

Can you work with a stress fracture of the tibia?

A medical leave is often prescribed when someone has a stress fracture in the tibia.

How long is the duration of the medical leave? Of course, it will depend on your occupational activity.

If you work from home all day, sitting behind a computer or talking on the phone, a medical leave may not be necessary.

On the other hand, if you have a physically demanding job that involves a lot of walking or lifting, a medical leave will be necessary for a few weeks or even months for the most physically demanding activities.

How long does it take to recover a stress fracture of the tibia?

Most people who have a stress fracture in the tibia are eager to resume their activities as before. And you are probably among those people!

However, let’s not forget that this type of fracture is often caused by overloading during training. Therefore, a very gradual return is essential to minimize the risk of recurrence.

How long does the recovery and healing process take? It depends on how we define these terms, as both recovery and healing are lengthy processes that are difficult to quantify objectively.

Healing often takes several months, as it can take up to 24 weeks (almost 6 months) for the bone density to return to normal (Jatsy 2021).

I consider that one is recovered when they are able to resume all their activities prior to the fracture.

This can take anywhere from 2 months to 1 year, which is quite a wide range, I must admit. But it reflects the reality of the situation!

When can I resume sport and running after shin stress fracture?

On average, people resume sports activities after approximately 14 weeks following a stress fracture of the shin, which is a little over 3 months (Jatsy 2021).

Women tend to resume sports activities slightly later. Some suggest waiting even longer, as it takes 24 weeks for bone density to return to normal (Jasty 2021).

Of course, this is an average, and individual cases may vary. Some people may return much sooner (within a few weeks), while others may take longer (after 3, 6 months of rest, or even more in cases of significant fractures).

Another study reported the following return-to-sport timelines:

• An average of 2 months, with 100% of individuals returning to their previous level of activity for posterior fractures.
• An average of 7 months, with 89% of individuals returning to sports for anterior fractures (Robertson 2015).

However, considering the high risk of recurrence, it is crucial to carefully weigh the pros and cons of an early return to exercise.

Certain high-risk fractures may require more than 6 months of sports cessation or progressive retraining. Early returns to sports reflect the impatience of athletes and healthcare professionals to avoid long periods of inactivity. However, overly ambitious protocols can lead to recurring injuries if the injured bone is not allowed to fully heal or if there is a lack of appropriate progression in impact activities.

Jatsy 2021

The idea is to resume activities gradually after hairline fracture. It is often suggested to increase the workload by 10% per week, although there is no empirical evidence to support this specific percentage (Bolthouse).

Is recurrence frequent?

Fractures of the posterior-medial border of the tibia generally have better recovery outcomes and lower recurrence rates compared to those of the anterior border. Fortunately, fractures of the anterior border are less common, accounting for approximately 10% of cases (Jasty 2021).

The only figures I found regarding the recurrence rate are as follows: recurrence rates range from 11% to 36% in a population of highly active people (military personnel) (Rauh 2006).

Are there any long-term effects?

In the majority of cases, people are able to resume sports activities at the same intensity as before. However, some people may experience chronic pain or discomfort, which can prevent them from returning to the same level of intensity.

Reliable data on this subject are scarce, but it is estimated that around 45% of people who have had this stress fracture may have lingering symptoms or are unable to return to the same level of intensity (Jasty 2021).