Pain location is an important component in clinical diagnosis. In the diagnosis of tibial stress fracture, it is vital to localize exactly where the patient feels the most severe pain, either at rest or with activity. If necessary, it may be beneficial to have the patient run or jump for 5–10 min to reproduce the symptoms and better pinpoint the location of pain. The main additional differential diagnosis in the evaluation of shin pain in possible overuse injury is medial tibial stress syndrome, or “shin splints.” In diaphyseal tibial stress fractures, the pain is frequently insidious in onset, over a prodromal 2- to 4-week course, and often coincides with a change in training volume and/or intensity. Initially, the pain is after activity, then progresses to during activity, especially weight-bearing during running or jumping on the affected leg, and may progress to activities of daily living and/or at rest. Anterior or anterolateral, tension-sided, tibial stress fractures often present in jumpers, ballet, or dancers at the central one-third of the diaphysis and the athlete typically points with one finger “this is where it hurts.” Compression-sided fractures often present in runners at the posteromedial tibia (similar to medial tibial stress syndrome). However, these fractures may present proximally, distally, or in the mid-shaft. Patients may point to a focal area of pain or may more broadly or vaguely state that “it hurts around this area.” Patients with medial tibial stress syndrome similarly complain of vague diffuse exertional pain along the posteromedial border of the tibia at the mid-distal portion of the shaft.

Patients with stress fractures in other locations of the tibia often complain of focal tenderness to touch and weight-bearing pain. Similar to diaphyseal fractures, these fractures may initially be only after activity, progress to pain with activity, and eventually be present with activities of daily living and/or rest. In medial malleolar stress fractures, patients will complain of weight-bearing pain at the medial malleolus, especially with running, and pain with ankle motion. In patients with proximal tibia stress fractures, activity-related weight-bearing pain is common at the location of the fracture.

Circumstances that aggravate a painful sensation often clue the clinician into the diagnosis. Factors that relieve pain include rest, medications, and procedures. In patients with tibial stress fracture, exacerbating factors include running (e.g., compression side posteromedial tibia), jumping or dancing (e.g., tension-side anterior tibia due to force of posterior calf musculature), and weight bearing (e.g., ambulation). Relieving factors usually include rest, reduction in weight bearing and loading of the leg, anti-inflammatory medications, and ice cryotherapy.

A helpful history pearl that may distinguish medial tibial stress syndrome and tibial stress fracture is the pain response to a training session. Patients with stress fractures tend to have worsening of pain in the location of the fracture with a single training session as the session progresses to the point that the athlete sometimes has to stop due to pain. Athletes with medial tibial stress syndrome, in the early stages, may actually have pain at the beginning of a training session that gradually subsides during that training session.

The clinician must be cognizant of other possible contributing coexistent pathology that may predispose the athlete to stress fracture. A thorough foot exam may reveal rigid pes cavus, subtalar pronation, tarsal coalition, muscle imbalance, weakness, or stiffness. Pes planus has also been shown to predispose to medial tibial stress syndrome [8]. However, other studies have shown, rather than pes planus, it is the ratio of subtalar everter to inverter muscles (in favor of eversion) that is predictive of increased risk of medial tibial stress syndrome [13]. Evaluation of leg-length is necessary as a significant leg-length discrepancy is associated with tibial stress fracture [14].

The key physical examination finding to distinguish a tibial stress fracture from other causes of leg pain is primarily focal point tenderness at the location of the fracture, usually the anterior or medial tibia. As opposed to the latter, patients with medial tibial stress syndrome frequently have more diffuse, nonfocal tenderness along the posteromedial middle to distal one-third of the tibia and not the anterior tibia. If the patient reports that the pain only occurs after an activity, such as running, then the clinician should have the patient go outside of the clinic and run, or in the training room or physical therapy arena, run on a treadmill. The tenderness may be exacerbated by a tuning fork test. The tuning fork test has a sensitivity, specificity, positive predictive value, and negative predictive value of 75 %, 67 %, 77 %, and 63 %, respectively. The single-leg hop test is also frequently utilized in the evaluation of all lower extremity stress fractures, not just the tibia [18]. However, this test is nonspecific, as it is also positive in up to 46 % of patients with medial tibial stress syndrome [19]. Edema and palpable periosteal thickening are also observed in patients with tibial stress fractures. In patients with medial tibial stress syndrome, edema is usually absent.

Thorough inspection of the tibial stress fracture requires observation of the core and entire lower extremity. In addition to the patient himself/herself, shoe wear patterns should also be observed. One should also note prior surgical incisions and observe any deformity or asymmetry in alignment, swelling, calluses, and blisters. The clinician should observe for any swelling, edema, ecchymosis, or erythema. Gait evaluation by either observation in clinic or outside of clinic, on a treadmill or via digital video analysis gives a real-time evaluation of biomechanical factors that may predispose to stress injuries of the tibia (Fig. 10.1a–c).

This is a key component in the tibial stress fracture evaluation. All osseous and soft tissue structures warrant palpation. In the leg, this includes, among others, the subcutaneous tibia, the knee joint, tibial tubercle, fibular head, medial and lateral malleoli, the popliteal fossa, calf musculature and Achilles tendon, and plantar fascia. The patient with a tibial stress fracture may exhibit focal tenderness with percussion testing, a positive tuning fork and single-leg hop test, and edema. Patients with medial tibial stress syndrome usually exhibit more diffuse, nonfocal tenderness along the posteromedial mid-distal tibia without edema. Patients with medial malleolar stress fractures have tenderness over the medial malleolus and pain with forced passive ankle dorsiflexion and rotation.