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Stress Fracture return to activity

Exit forum ID Forum Discussion Stress Fracture return to activity

This topic contains 5 replies, has 2 voices, and was last updated by   Carl Nottoli, DC May 14, 2018 at 5:32 pm.

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    Andrew Wengert

      First order: 25 Year old female. Jabbing pain along the distal shaft of the tibia. Patient says it gets up to a 6/10, average is a 1-2/10. Provocative is running, jumping, going down stairs. Rest is palliative.

      Second order: Pain started 3 months ago after starting crossfit, specifically after a double under clinic. Symptoms were getting better but any time she runs in her workouts, it flares up. She currently does crossfit 3 days a week. Patient is also an ultimate frisbee player who would play/practice 3-4 days/week even prior to starting crossfit.

      Pain is there at the beginning of activity, get numb after “warming up”, then be really sore the next day with loading.

      Physical exam: There is a two inch tender area along the distal shaft of the femur.

      Dorsiflexion was 6″ Bilaterally with mild stretching. PK test was full range with mild stretching. Patient could achieve full lock out with two legs, but was limited with 1 on both sides.


      1) Stress fracture of the tibia

      2) Weakness of the deep calf muscles

      Patient was instructed to avoid all running, jumping, and impact activities for 2 weeks. Patient was also given the single leg calf raise exercise to strengthen the deep calf muscles.

      I have 2 concerns:

      1) Should I be more concerned that a 25 year old female who was already participating in physical activity is getting symptoms like this when she has such good function? Should I be considering diet, metabolic, etc?

      2) How do I progress this patient back into impact activities. Do I take into account her pre-injury activity level? Or do I start her at an absolute minimal amount of loading and slowly progress?


      Carl Nottoli, DC

        First off, do you have images to confirm the stress fracture? If the fracture is present it should be self evident that the patient removes all activity and should be in a boot (or potentially crutches).

        Secondly, from the history tendinosis of the peroneal group would also be on my list. Again imaging can help confirm this as well.

        To your questions:

        A 25 year old female that is overtraining could have metabolic issues. You can start digging a little by asking about diet and any other self-imposed restrictions.
        She is not ready for any loading activities until the diagnosis is solidified. Stress fracture and tendinosis need to be handled differently when load is re-introduced.

        Make sense?



          After reading over this case and answering it to myself before reading further, Tendinosis of the Peroneal group was not on my radar.

          What in the history pointed in this direction?

          I don’t like when I miss a potential diagnosis.



          Carl Nottoli, DC

            My apologies. I misread tibia for fibula. So peroneal tendinosis is off the list.

            Andrew, can you point to the location of pain on yourself and take a picture? This will help us get a better tissue list formulated.


            Andrew Wengert

              Between my fingers is the area of complaint. There is no symptom or tenderness in the soft tissue structures, only the bone.

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              Carl Nottoli, DC

                Bone stress fracture/stress reaction is top of the diagnostic list. They need to be on rest until the bone heals.

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