(Kiosk 2) Delayed Presentation of Bilateral Tibial Stress Fractures in a Pediatric Soccer Player: A Case Report

Case Diagnosis: Bilateral tibial stress fractures

Case Description or Program Description: A 14 year-old, otherwise healthy, female presented with subacute bilateral (left > right) anterior shin pain for about 3 months during her first soccer season in 2.5 years. She initially had shin pain after soccer games that progressed to pain with walking yet continued to play. She denied previous fractures, mood and eating disorders, and had regular menses for the past 2 years. She had appropriately fit cleats. She denied low back pain and sensory changes in her legs. On exam, she was tender to palpation in the proximal third of the anterior tibia bilaterally, had an antalgic gait with ambulation, was hesitant to do the hop test, had positive tap/percussion tests at the heels, and weakness for heel lifts secondary to pain.

Setting: Outpatient setting

Assessment/Results: Initial XR bilateral tibia/fibula demonstrated focal periosteal reaction and cortical thickening with faint oblique lines at the medial proximal tibias. MRI legs noted tibial stress reactions with intracortical linear signals posteromedially corresponding to Fredricson grade 4b. Treatment was NWB with wheelchair at school and WBAT with crutches and alternating CAM boots at home for 8 weeks; WBAT with crutches and alternating CAM boots for 4 more weeks; and then FWB and PT with gradual return to sports.

Discussion (relevance): Stress fractures account for 10% of all sports-related injuries with higher incidence in runners and females. The tibia is the most affected bone, but it is very unusual to present with simultaneous bilateral tibial stress fractures. Our patient has no known medical conditions that would predispose her to stress fractures let alone bilaterally.

Conclusions: This case illustrates the importance of early recognition of symptoms specifically bilateral anterior shin pain with limping for pediatric athletes so that diagnosis and management can be pursued in a timely manner.