Of all the long bones in our bodies, most fractures occur in the tibia. Also known as a shin bone, it connects your knee to your foot. Your tibia is crucial for the stability of your leg and it is designed to handle the impact of walking, running, or jumping. So, what happens if something like a fracture disturbs this stability? Suddenly, daily things like standing and walking feel impossible to do. Even if you have surgery to fixate your broken tibia, the recovery is tough.
Apart from the obvious cracked bone, a tibia fracture causes damage to arteries, veins, nerves, ligaments, or even muscles. This is often overlooked, which either leads to serious complications or slower recovery. Regardless of whether you had a tibia fracture years ago and never fully recovered, or recently injured your shin, and are not even sure if you fractured it. This article is for you.
What is a tibia and where can I find it?
Tibia means “shin bone” in Latin. If you rub your hand over the front of your shin (the lower part of your leg beneath your knee), you will feel the hard ridge of the tibia bone. It is the second largest bone in your body. It forms part of your knee and ankle joint and almost every centimeter is covered in layers of muscles that control knee, ankle, foot, and toe movements.
The structure of the bone
At the top, the tibia has a broad, flat area called the tibial plateau. It forms the lower part of the knee joint. There are three prominent points at the top. Two of them are called condyles and the middle one is called the tibial tuberosity. Muscles and tendons attach to them.
The middle part of the bone is called the tibial shaft.
At the bottom, the tibia connects to the ankle bone (talus) and the fibula. Together they form the ankle joint. Here, the tibia forms an important prominence, called the medial malleoli. This is the knob that you can see and feel sticking out on the inside of your ankle. Important ankle ligaments attach to the malleoli.
Other important structures
Several important arteries, veins, and nerves can be found alongside the tibia. Different groups of muscles attach to the tibia. These muscle groups are divided into compartments and are covered with a sheath.
- Anterior (front) compartment: The tibialis anterior muscle, extensor hallucis longus, and extensor digitorum longus are responsible for lifting your foot and toes.
- Superficial posterior (back) compartment: Big calf muscles (gastrocnemius and soleus) that lift your heel when you stand.
- Deep posterior (back) compartment: Nerves and arteries of your lower leg run here, as well as the tibialis posterior, flexor hallucis longus, and flexor digitorum longus muscles that bend your ankle and toes.
What is so important about the tibia?
- The tibia connects your knee to your ankle.
- It forms a part of the knee and ankle joints, allowing you to bend your knee and lift your foot.
- The tibial plateau and condyles are an attachment point for knee ligaments and menisci.
- These ligaments, together with the meniscus give your knee stability.
- Important ankle ligaments connect to the medial malleoli and help with ankle stability.
- Your tibia helps to distribute the weight of your body across the knee and to the ankle.
- When you walk, your tibia can handle impact forces up to 4.7 times your body weight.
- Muscles that move your knee, ankle, and toes attach to your tibia.
- Muscle compartments around your tibia form a ‘pump’ that helps circulate blood from your feet back to your heart.
I have a tibia fracture. How does it happen?
A fracture is a crack in a bone. This can be anything from a thin, hairline crack to a much more serious fracture where the bone shatters into two or more pieces. You need a force, like a fall, twist, or crash to cause a tibia fracture. The location of the fracture determines how critical it is together with the degree of fragment separation.
The first thing your body does in response to a fracture is to cause an immediate and severe inflammatory reaction. This is an influx of repair cells to the injury site, all these cells accumulate causing a very powerful immune response leading to swelling and increased pressure and pain. Walking or stepping on your injured leg produces sudden, sharp, intense pain because it compresses the fractured bone pieces together. These fractured tibia segments can tear through blood vessels and pierce muscle, ligament, or nerve tissue.
It’s a serious injury
To have a broken tibia is a serious injury. The first step is to get a clear X-ray of the broken tibia fragments to determine the type of fracture. Tibia fracture treatment is determined after you know the extent of the damage. Bone can grow back together again, but it will take time and might need surgery.
Classification of a fracture
- Stable (non-displaced) fractures – also known as a clean break, the fragment pieces of the tibia line up.
- Displaced fracture – one part of the bone shifts and the pieces don’t line up anymore. Thus, the bone can’t heal properly. This type usually needs surgery.
- Stress fracture – small, hairline cracks that are typically caused by overuse i.e. constantly overloading the bone.
- Spiral fracture – caused by a forceful twisting movement, it causes a spiral-shaped fracture. The tibia usually doesn’t line up and this type of fracture requires surgery.
- Comminuted fracture – the bone shatters into three or more parts. This is a complex injury because the sharp ends of the broken bone can cause damage to nerves or blood vessels.
- Avulsion fracture – a ligament or tendon pulls a small piece of bone from the tibia. This usually happens where your patella tendon is anchored at the upper part of your tibia or on the inside of your ankle where important ankle ligaments attach to the malleoli.
- Greenstick or incomplete fracture – when one side of the bone cracks and the opposite side bends without breaking. This injury is only found in children because their bones are softer.
- Open vs closed fracture – when the skin and muscle over the tibia is torn, with a piece of the bone sticking out, it is called an open fracture.
A stress fracture can be just as serious
Often, a tibia stress fracture is caused by too much repetitive impact. This includes running and jumping. It might sound like a small crack in the tibia, but the pain can be just as debilitating. A stress fracture can lead to a full-blown fracture if it isn’t managed the right way.
Causes of tibia fractures
- Falling directly onto your knee or shin
- Severe impact like a car crash
- Jumping or falling from a height
- High-impact sports like skiing, horse riding, hockey, rugby, or gymnastics
- Repetitive impact through your tibia like long-distance running
Risk factors that increase your chances of a fracture
- Osteoporosis – Low density and poor bone structures make your bones more vulnerable to fractures
- Gender – Women, especially post-menopausal, are more prone due to problems with bone density
- Medications – Some medication side-effects cause a decrease in bone density like long-term use of cortisone
- Nutrition – Lack of calcium and vitamin D leads to poor bone structure development
- Age – Persons with higher age have a bigger chance of falling due to weakness and poor balance
- Training intensity, frequency, or duration – a sudden boost, accelerating into any of these (especially high-impact training) puts more strain on your tibia bone.
- Training surfaces and inappropriate footwear – Changing from a treadmill to road running or using worn-out shoes increases the load going through your tibia, which is poorly conditioned to absorb the volume of crunching force through your tibia.
How bad is it?
Although there are many different types of tibia fractures, each one is still a serious injury. We look at a few things to help us determine the severity of your problem.
Swelling
Swelling is a common and significant response to tibia fractures. The bone fragments cause injury to the surrounding muscles, blood vessels, and nerves. In the acute phase following the fracture, your body’s inflammatory response triggers the release of fluid and immune cells to the injured area, leading to visible swelling. The swelling can often increase within the first 48 hours. This adds to the pain that you feel and restricts your movement even more. If the swelling and pressure keep building, it leads to complications like compartment syndrome. This severe complication leads to extreme pressure within the muscle compartments in your lower leg, bringing all circulation to a standstill.
Bruising
When the bone fractures, it damages blood vessels, leading to internal bleeding and the accumulation of blood in the tissues around it. This results in the characteristic discoloration of your skin, which appears red, purple, or blue around the injury site. While bruising is a natural response to injury, extensive or unusually severe bruising indicates significant tissue damage and the need for further medical attention.
Impact on the Knee and Ankle Joint
The tibia connects to your knee joint at one end and your ankle joint at the other. A tibia fracture causes misalignment or instability that impacts the function of one (or both) of these joints, depending on the exact location of the fracture. Important ligaments and muscles attach to the tibia and can often be injured or torn in conjunction with the fracture. Once you have injured or fractured a part of the joint, it increases your chances of developing arthritis in the future.
Ability to put weight on your injured leg
A tibia fracture will compromise your leg’s ability to carry any weight. Standing or walking becomes almost impossible to do. Putting weight on a cracked or broken tibia pushes and grinds the broken ends together, causing a lot of pain. While the tibia is usually a strong bone, its structure becomes very unstable when it is fractured. So, each time you take a step, it feels like your leg wants to give way beneath you. Pushing through the pain worsens the problem and leads to more damage around the fracture. The severity of the tibia fracture will determine whether you’ll be able to put some weight on your leg, or nothing at all. And don’t underestimate the severity of a tibia stress fracture. It might sound like it is ‘only a crack’, but it can cause pain that is just as severe and limiting as a more severe fracture. If a crack isn’t managed the right way from the start, it leads to a more severe fracture. That is why it is important to get the right treatment for your tibia fracture.
Diagnosis
Physiotherapy diagnosis
Our physiotherapists are experts in human anatomy and movement with the necessary experience to diagnose a serious injury to your tibia and shin. Even if you had a broken tibia in the past and you are still struggling with lower leg pain, we can accurately diagnose your problem, identify the relationship with the known history, and develop a treatment plan. Sometimes your pain is directly related to a past injury, but it could easily be a new issue.
During your evaluation, we use movement in different ways to test stability, balance, range, strength, and load bearing. We will also test the surrounding muscles, joints, nerves, and tendons to confirm or rule out other injuries. That way, we can get the best idea of what exactly is causing your pain and determine the best treatment plan for your specific injury.
X-rays
X-ray imaging is an effective way to show the bone integrity and alignment of your ankle, knee, or shin bone. This is the cheapest fastest way to visualize and rule out a fracture. The fracture site, size of fragments, separation, and location are crucial to determine the treatment approach.
Your physiotherapist will refer you for X-rays if necessary.
Diagnostic ultrasound
Diagnostic ultrasound is the second option if your X-rays show no abnormalities. It can be useful to identify signs of a stress fracture by looking for bone bruising, bone oedema, and periosteal thickening, and even rule out muscle tears, tendon ruptures, or ligament sprains.
If you need an ultrasound, your physio will refer you.
MRI
An MRI or CT scan shows all the structures in and around your knee, ankle, or shin bone. This includes bones and soft tissue like muscles, ligaments, and nerves. This test is useful if we suspect that the fracture extends into your knee or ankle joint, involving the connecting surfaces of the joints. However, these tests are expensive and not always necessary from the start.
If your physiotherapist suspects that you have a tibia fracture or a deeper soft tissue injury in your lower leg, you will be referred to the right specialist for further imaging.
Why is the pain not going away?
If you’ve fractured your tibia, it’s important to understand that the bone won’t heal properly without the right treatment. If you decide to “wait and see,” hoping it will heal on its own, there could be some serious consequences. The tibia is a weight-bearing bone that provides stability to your leg. It should be aligned correctly while it heals to ensure it is as strong as before.
Problems with healing
Without treatment, the bone might not heal like it should, leading to malunion, where the two ends heal in a misaligned position. This results in a visible deformity, chronic pain, and trouble walking. In some cases, the bone may not heal at all (also called nonunion). That will require more invasive medical treatment later. The important thing to remember is once a bone heals incorrectly, you can’t undo it. No amount of rest, training, or stretching will fix that. It will feel like a massive setback if you find out that your tibia has not healed optimally and you’ve already struggled through weeks of this injury.
Proper diagnosis will guide your recovery
Getting an accurate diagnosis guides the prognosis (recovery time). This includes getting the right medical treatment and working through a proper rehabilitation program. Recovery through physiotherapy and rehabilitation will spend a lot of time fixing the secondary fallout caused by the fracture namely the muscle tears and weakness, torn ligaments, and overloaded tendons. We help strengthen your leg and rebuild your tibia’s capacity to endure and absorb load safely.
Tibial stress fractures are particularly challenging and poorly managed in the medical profession due to their biomechanical nature of origin. This means that muscle imbalances, foot alignment, training intensity, and many other components all contribute to causing a crack in your tibia. People often treat it like a casual thing and hope that it will go away. However, it is still a fracture.
Problems that we experience when we see patients with tibia fractures
Waiting too long to start with rehabilitation
Often, patients feel they need to rest and recover for a few months after a fracture when they can start with safe movements quite soon after. Even movements of other muscles and joints in your leg are better than nothing. You lose muscle strength and mobility a lot quicker than you think. And in the process, you learn wrong movement patterns that make the recovery process a lot longer.
Trying out, but not completing treatment
Recovering from a tibia fracture can be intense and painful. It forces your life to a standstill (quite literally), especially if you can’t even walk initially. However, if you don’t address the pain and problems in the weeks and months after your tibia fracture, it creates new long-term problems. Often, the bone heals very well, but months after the injury, people still experience pain and limitations in their ability to work or exercise. Chances are good that the pain you are experiencing at this stage is due to poor knee and ankle stability, weak muscles, and a poor walking pattern. The only way to address this is by working through all the steps of a rehabilitation program. The aim should be for your tibia and surrounding soft tissue to get used to carrying weight again. It takes time and effort, but it will be worth your while.
Relying on too much (or too little) medication
Pain medication is a great tool to help with pain relief, especially in the initial acute phase when inflammation and swelling are also at their highest. However, long-term use of medication has negative health effects and ideally, the pain should be improving as your body works through the healing process. An active approach (which includes safe movement) is much better than passively relying on pain medication alone to fix the problem.
Use of crutches
While recovering from a tibia fracture, you will need to use crutches or a walking frame initially. It is important to take weight off the fractured tibia, to encourage your body to heal the broken bone. However, you can get very dependent on a crutch and even fearful to walk without it. Gradually you need to stop using crutches and walk without any help to encourage bone remodeling and hardening.
Physiotherapy treatment
Our experienced team of physiotherapists can help you find the cause of your shin pain and get rid of the uncertainty. We know the right questions to ask and which tests to do to either confirm or rule out a tibia fracture.
Your first session will always start with a detailed assessment to get as much information as possible about your problem. This gives us an idea of possible diagnoses and which tests we need to perform. Testing involves putting stress on different structures like the knee joint, ankle joint and surrounding ligaments, muscles and tendons to find the root cause. We also look at muscle strength, joint range of motion, flexibility and quality of movement.
During the course of treatment your physiotherapist will provide guidance and answers while implementing an effective plan of action. Therapy is not a sprint, it’s a journey and our experienced health professionals are with you, every step of the way.
Phases of rehabilitation
1st Phase: Inflammation and pain control
Pain control is first up, so that your day-to-day movements feel manageable. Initially, you won’t be allowed to step on your leg, you will have to use crutches. Pain medication is very helpful during this phase. Resting and elevating your leg is crucial.
Our goal during this phase is to allow for bone healing and move only within the limits of your pain. We can encourage tissue healing by using dry needling, laser, strapping and neural mobilisations.
2nd Phase: Range of motion
As your pain starts to improve, our goal shifts to improve your range of movement. Especially in your knee and ankle. We use joint , neurodynamic and soft tissue mobilisations to improve the available range of motion. Your physiotherapist will start with safe, non-weightbearing exercises like isometrics and isotonic muscle contractions.
To progress to the next phase, you should be able to bend and straighten your knee fully. As well as move your ankle in a full circle.
3rd Phase: Weightbearing
Using crutches and not stepping on your injured leg is bound to set back your walking pattern. Often, just getting used to putting pressure through the tibia and lower leg is an exercise in itself. You’ll need to work on balance and leaning with all your weight on your injured leg when it is safe to do so.
At the end of this phase of your treatment, you must be able to stand, walk and balance on the fracture’s side with as little support as possible.
4th Phase: Muscle strength and joint stability
This phase of treatment focuses on strengthening the muscles surrounding your tibia. Repeated contraction of muscles, improve their strength. Stronger muscles have the capacity to work harder and give better stability to your knee and ankle joints. Standing up, walking and climbing stairs are some of the basic activities that you must get back to. With time , we progress your exercises by adding resistance, doing more repetitions and using multi-directional movements, like climbing up a step, as part of your strengthening program.
By the end of this phase you must be walking without any crutch and walk at a slow pace on even terrain. You should be able to climb down a stair without support.
5th Phase: Stimulate bone remodeling
Gradually returning to your routine and getting used to the intensity of your usual activities is a big part of your recovery. We need to determine if you are ready to return to fully working and exercising without any painful flare-ups. Even with repetitive movements throughout your day (like walking around your office) or more load (like running), your tibia and the surrounding muscles should be able to carry the load. As your body gets used to doing more again, the fractured bone structure actually gets stronger.
Here the milestones are achieved when you can do single leg squats, hop on one leg, jump down from a step and land on your injured leg while keeping your balance.
6th Phase: Sport specific training and final clearance tests
Certain activities require precise balance, high power, speed and endurance. We need to ensure that your tibia is able to handle the stress that these activities puts on it. Your physiotherapist will challenge you past your normal boundaries with this more advanced program to prepare you for external reaction forces and multi-directional stability. All of this needs to happen in preparation for your return to your sport.
Healing time
It takes anywhere between 6 to 12 weeks for the initial healing of your broken tibia bone to attach. Getting back to a fully functional level and actively exercising or participating in sport takes 3 to 6 months. Many indirect factors can accelerate or even slow down recovery, and that is why it is important that a physiotherapist monitors your progress. To adjust, adapt and overcome temporary setbacks and keep the momentum going in your recovery.
Together with a tibia fracture, other surrounding muscles, nerves or ligaments usually get injured as well. This complicates things and increases your recovery time. At first, our main concern is bone healing, but during the weeks and months it will take to recover, there are numerous things that needs our attention as well. It is important to start with physiotherapy as soon as possible to prevent longstanding problems of compensation, muscle weakness and poor healing. Initially, you must attend physiotherapy treatment twice a week. After this, your treatment sessions are spread out to once a week or once in two weeks.
It is important that you get a follow-up x-ray about 12 weeks after your initial injury to monitor bone healing. Your orthopaedic surgeon or physiotherapist can refer you for x-rays. If your bone structure heals well and you complete your physiotherapy treatment protocol, you should be able to recover completely and return to your sport.
Other forms of treatment
- General practitioner (GP): Your doctor can help with a prescription for pain medication if pain persists.
- Chiropractor: Your knee or ankle might feel stiff after you had a tibia fracture. Maybe it feels like it needs to be ‘clicked’ back in. However, getting a manipulation or re-alignment done is not a good idea. At worst it could put pressure on healing bone.
- Biokineticist: When you need help with supervised exercise sessions to take your rehabilitation further, a biokineticist can also help you with that.
- Orthotist: An orthotist can provide crutches, a moonboot or a walking frame according to your measurements and needs.
Will I need surgery for a tibia fracture?
There is more than a 55% chance that treatment for your tibia fracture will involve surgery to secure the different bone fragments. An orthopedic surgeon uses various devices such as nails, plates, screws, and rods to stabilize and fixate the tibia fracture. The only type of tibia fracture that doesn’t need surgery is a stress fracture or an undisplaced closed fracture. If surgery isn’t indicated, you still need to wear a cast to stabilize the fracture, allowing it to heal.
After surgery, rehabilitation is the only way to get you back on your feet. Initially, your surgeon might not permit certain movements and you won’t be allowed to step on your operated leg. However, you are allowed to start with physiotherapy in the first few days after your surgery. Your physiotherapist can help you by passively moving your leg and showing you safe exercises to do. This way, when the orthopedic surgeon gives you the green light to start moving, your physio is up to date and ready to progress your treatment.
We work with a network of expert orthopedic surgeons who have proven their expertise and can refer you to the best specialist that suits your problem. Post-operative rehabilitation is what we do best, whether it happened recently or years ago.
What else could it be?
- Shin splints – deep, severe ache right against your shin bone that gets more intense and sharper with exercise, especially running.
- Tibialis anterior tendonitis – superficial ankle pain that feels worse when you flex your foot (pull your toes up towards you). Specifically sore with movement, not bearing weight.
- Osgood Schlatter’s disease – knee pain just below your kneecap that feels worse when getting up from a chair, running, or jumping. Often seen in children and teenagers.
- Patella tendonitis – an overuse type of knee pain, similar to Osgood Schlatter’s. Knee movements (specifically the use of the quadriceps muscle) worsen the pain.
- Knee osteoarthritis – stiffness and pain in your knee joint that specifically feels worse in the mornings. It eases with movement as your knee “warms up”.
- Ankle ligament sprain – overstretched or torn ankle ligaments after you’ve ‘rolled’ your ankle. It typically causes swelling, bruising, and pain on the outside of your ankle that feels worse when you try to step on your injured foot.
Also known as
- Proximal tibia fracture
- Tibial shaft fracture
- Distal tibia fracture
- Fractured shin bone
- Stress fracture of the tibia
- Broken ankle
- Knee fracture
