Left Shin Pain - Ballet

HISTORY: A 21-year-old female professional dancer presented for progressive left shin pain onset three months ago. She had been dancing six days per week for eight hours each day at her ballet company. The pain was described as sharp, intermittent, and localized to antero-medial distal 1/3 of the tibia. Severity was 7/10 while dancing, 2/10 at rest. Pain was aggravated by weightbearing, leaping, going upstairs, and squatting. Ibuprofen provided minor relief. She had no history of stress fractures and had regular menstrual bleeds, for five days every 30 days. PHYSICAL EXAMINATION: BMI 20.3. Antalgic gait. No edema, discoloration, or warmth of left lower extremity. Point tenderness over the junction of middle and distal thirds of the anterior tibia. Intact distal pulses. Ankle dorsiflexion and eversion strength 4/5 with moderate pain; knee and ankle strength in other planes 5/5. Single left leg hop test with severe pain. DIFFERENTIAL DIAGNOSIS: Tibial shaft stress fracture, medial tibial stress syndrome, peroneal nerve entrapment, tibialis anterior strain TEST AND RESULTS: Left tibia-fibula x-ray: Multiple linear lucencies in the anterior cortex of the tibia with surrounding periosteal reaction. The fractures exhibit different stages of healing, with the most inferior lucency appearing to be the most acute. Left tibia-fibula MRI: Grade IVb stress fracture involving the distal tibial diaphysis. Multiple additional subacute chronic tibial stress fractures. FINAL WORKING DIAGNOSIS: Anterior cortex tibial shaft stress fractures TREATMENT AND OUTCOMES: 1. Referral to Orthopedic Surgery to discuss surgical options including intramedullary nailing vs anterior tension band plating. Ultimately decided on non-operative, strict non-weightbearing management with close monitoring: NWB for first 6 weeks, WBAT with crutches weeks 6-10, FWB after 10 weeks, and stepwise return-to-sport with performing arts physical therapist. 2. Relative energy deficiency in sports work-up notable for iron deficiency, borderline anemia, low vit D. 3. Bone density within expected range for age (Z-scores +1.4-2.1). 4. Iron, vit D, and calcium supplementation with referral to sports dietitian to optimize fueling. 5. She has returned to dancing without pain. She is still at half the training load of pre-injury and progressing slowly.