Tibial stress fracture — CCFP MCQ

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HardMusculoskeletal and sportsTibial stress fractureCCFP

A 16-year-old competitive distance runner presents with focal shin pain that worsens with running and improves with rest. On examination, there is focal tenderness over the medial tibia, and the hop test reproduces her pain. Her menstrual periods are infrequent. Plain radiographs of the tibia are normal. What is the most appropriate next investigation?

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Correct answer: C — MRI or bone scan for suspected tibial stress fracture

**Correct answer: B** This patient has a clinically high-probability tibial stress fracture: focal tibial tenderness with a positive hop test in an elite adolescent runner with infrequent menses (female athlete triad: energy deficiency → low bone mineral density → stress fracture risk). Normal plain radiographs do *not* exclude stress fracture; early stress fractures often appear normal on X-ray and may not show periosteal callus or cortical changes for 2–3 weeks. After high clinical suspicion and normal plain films, the appropriate next step is advanced imaging—either MRI (first choice: no radiation, excellent soft tissue and marrow detail) or bone scintigraphy (alternative: high sensitivity, wide availability). **A** delays diagnosis dangerously. **C** (serum urate) is irrelevant; crystal arthropathy does not present with exertional pain, positive hop test, and athlete history. **D** (arthroscopy) is invasive and inappropriate; there is no intra-articular pathology. **E** risks progression to complete fracture and prolonged disability.

Reference: American College of Radiology Appropriateness Criteria for stress fractures (via PubMed); Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. PubMed 2016. https://pubmed.ncbi.nlm.nih.gov/27002328/