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as the disease advances, cartilage has usually been damaged and penetrated to the bone surface, and bone remodeling can shift the stresses and strain in the damaged area to the subchondral bone. consequently, increasing bone resorption by osteoclasts increases the bone stress on the opposite side of the bone, resulting in a stress fracture ( 25 ). fig8c. fatigue stress fracture of the tibial spine. plain films of the knee showed mild joint space narrowing with osteophytes. osteophytes of the femoral condyles and tibial plateaus were visible (fig 8c). fatigue stress fracture of the spine was diagnosed by radionuclide bone scintigraphy, which demonstrated intense uptake of the radionuclide in the lateral tibia (fig 8d). fatigue stress fractures show low-uptake uptake on tc-3-d-phenix bone scintigraphy, whereas a routine bone scintigraphy demonstrates no uptake. ct is more useful than mri in identifying sites and severity of the fracture. high-intensity areas in the bone marrow and sclerosis along the fracture line are typical findings in ct. however, they are subtle features, and ct shows nonspecific findings due to the overlapping signal intensity between the fracture and surrounding soft tissue and healing tissues. fatigue stress fractures may be misdiagnosed as common tumors, such as bone metastases, due to the intensity of uptake in the bone marrow on radionuclide bone scintigraphy and ct ( 3, 6, 7, 34 ).
in the present study, five cases had posterior tibial stress syndrome with a reported potential of developing a fatigue stress fracture. the development of a posterior tibial stress fracture can be primary or secondary. anterior tibial stress fracture is also well known for its potential to develop into a posterior tibial stress fracture. nevertheless, posterior tibial stress fracture (17) or a fatigue stress fracture of the posterior tibia (17) that developed into a fibula fracture was reported only once. we think that posterior tibial stress syndrome is important in the biomechanical pathogenesis of fatigue stress fracture by increasing the force applied to the tibia during loading, thereby reducing bone mass and biomechanical stability, and finally leading to fatigue failure of the tibia. additionally, ankle inversion was observed in the present cases, which may have also contributed to the development of posterior tibial stress syndrome, fatigue stress fracture, and fibular stress fracture (15, 22). in the present cases, we performed medial malleolar and medial femoral fractures in two cases, which sometimes occur due to posterior tibial stress syndrome. nevertheless, the relationship of those fractures with posterior tibial stress syndrome is unclear. the present study did not present a report of posterior tibial stress syndrome with no one having a fibula fracture in the present cases.
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