Intramedullary Nailing of Tibial Stress Fractures

Intramedullary nailing of tibial stress fractures is a viable option in a very limited subset of patients that fail nonoperative management. It may be more likely to be required in those patients with the more difficult anterior stress fracture variant. The primary limitation of the technique, however, is the potential for the development of anterior knee pain that may itself be disabling in the athlete. There is at least some risk that anterior knee pain, if it develops, may persist following nail removal. A peritendinous incision is still recommended although strict literature support is lacking, and burying the nail in the bone as evidenced on the lateral radiograph remains a good practice. Although it may be debated whether or not medial tibial stress syndrome represents a precursor lesion to tibial stress fracture, distinguishing between the 2 entities is important when posteromedial tibial pain persists. The former may be treated with a release of the soleus bridge, whereas intramedullary nailing (with its attendant risks) is the preferred choice for a persistent stress fracture.