The thought of breaking a bone is a painful one. And, of all the long bones in our bodies, the tibia is where most fractures occur. Also known as a shin bone, it connects your knee to your foot. Your tibia is crucial for stability of your leg and it is designed to handle the impact of walking or running or jumping. But, what happens if something goes wrong? A broken tibia makes basic daily things, like walking, impossible to do. And even if you have surgery to fixate your fracture, the recovery is tough.

Apart from the obvious cracked bone, Tibia fracture causes damage to arteries, veins, nerves, ligaments or muscles, that is often overlooked, which eventually leads to serious complications and slower recovery. If you had a tibia fracture years ago, but never recovered completely. Or maybe you recently injured your shin and you are not sure if you’ve fractured it. Then this article is for you.

Tibia means “shin bone” in Latin and that is exactly where you’ll find it. If you rub your hand over the front of your shin (lower leg), you’ll feel the tibia sticking out. It is the second largest bone in your body. Its part of your knee and ankle joint and almost every centimeter is covered in layers of muscles controlling the movements of your toes, foot and ankle and knee.

• Connects the knee to the ankle.
• Forms part of the knee joint, allowing you to bend and straighten your knee.
• The tibial plateau is an attachment point for your cruciate knee ligaments and meniscus.
• Muscles and ligaments attach onto the condyles of the tibia.
• These ligaments, together with the meniscus gives your knee stability.
• Important ankle ligaments connect to the medial malleoli and they 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 bodyweight.
• Weight transfers through your leg when you stand, walk, run or jump.
• Muscles that move your knee, ankle and toes attach onto your tibia.

Our skeleton is able to handle a lot of pressure, torsion and crushing forces. Your body constantly maintains the strong structure of your bones by producing new bone cells. A fracture is when there 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. Keep in mind that the tibia is a very strong and sturdy bone. So, you need an immense force, like a fall or a car accident, to cause a tibia fracture. The location of the fracture determines how critical it is together with the degree of fragment separation. Your tibia is most vulnerable against twisting and rotational forces when combined with a crushing pressure your tibia bone doesn’t need much to break.

Classification of a fracture

• Stable or 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, so the tibia isn’t aligned anymore. If the pieces don’t line up, the bone won’t heal properly. This type usually needs surgery.
• Stress fracture – small, hairline cracks form in the structure of the bone. This injury is 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 onto 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.

It starts with an injury

Let’s say you were in an accident and now you have extreme pain in your lower leg. Your pain shoots through the roof the moment you try to walk. Now, you’re wondering if you have a tibia fracture.

The x-rays show that you have a tibia fracture

You are referred for x-rays and it shows a clear fracture of your tibia. 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 produce sudden, sharp, intense pain, because it compresses the fractured bone pieces together. The velocity of force needed to break your tibia bone is quite high, these fractured tibia segments tearing through blood vessels, and piercing muscle tissue, rupturing ligaments and cutting through nerves causing severe instant blue bruising and swelling.

It’s a serious injury

To have a broken tibia is a serious injury, the first priority is to get a clear X-ray of the broken tibia fragments and classify your 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, discipline and effort. Often, surgery is necessary to fixate the different pieces of bone in the right position. If you continue walking with a tibia fracture, the movement between the bone fragments destroys the surrounding tissue which delays healing considerably.

It’s only a stress fracture

Let’s say your x-rays showed that you only have a hairline fracture or stress fracture. Often, an injury like this is caused by too much repetitive impact, combined with wringing forces that slowly breaks the tibia bone. This includes running and jumping. A stress fracture is not as serious and you certainly won’t need surgery, but you still need to fix how load is distributed through your leg. Chronic shin pain or shin splints eventually caves under the repetitive bone stress. A tibia stress fracture often leads to a full-blown fracture if repeated impact is continuous.

What if the x-rays showed it’s not a tibia fracture at all?

You can still have severe lower leg pain with soft tissue injuries. In fact, nerve and muscle damage is much more painful than a Tibia fracture because the bone has less ‘feeling’ due to less nerve innervation. Trauma to blood vessels, inflammation, swelling and bruising of the layers of soft tissue and muscles around your tibia can produce severe, intense lower leg pain.

Get your leg checked out if you suspect you have a fractured tibia, because it determines the type of treatment you need to recover. Our Physiotherapists can refer you for the necessary X-rays.

• 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:

Here’s the risk factors that increase your chances of a broken tibia.

• 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 medications 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 has a bigger chance of falling due to general weakness and poor balance.
• Physical inactivity – Physical activity in particular weight training stimulates bone growth with good density and muscle stability to control motion.
• 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, that’s poorly conditioned to absorb the volume of crunching force through your tibia.

Even though there’s many different kinds of tibia fractures, each one is still a very serious type of injury. If the fracture segments are displaced, it probably needs to be fixated back into place with surgery. When the bone shatters into many different fragments (comminuted tibia fracture), it is much harder to fixate all the pieces back together again. An open fracture makes it much more complicated, because now you have to recover not just from a fracture, but from soft tissue injuries as well.

When it comes to tibia stress fractures, early detection is key to unlock the true impact profile. This determines your risk before catastrophic failure. Would you continue to jump and sprint if you knew your tibia is actually cracking? Regardless of how your tibia is broken, getting the right guidance and treatment is crucial, whether you look at it from a medical perspective or a functional perspective.

It could be a life-threatening injury

• Tibia fractures can cause severe trauma to the surrounding tissue like tearing into muscle tissue and skin or cut through nerves and arteries that run alongside the bone. This leads to nerve damage and weakness.

• If the swelling in your lower leg gets too severe, it leads to compartment syndrome. The swelling builds up inside the muscle compartments of your lower leg and starts to compress arteries and nerves. In a case like this, surgery is necessary to relieve the pressure. Bleeding, swelling and circulation problems can cause blood clots in your leg. If a blood clot moves to your heart, lungs or brain this can cause a heart attack, stroke or pulmonary embolism.

• Lung infections (pneumonia) and can become a problem if someone is not moving enough after the surgery.

• Infection is always a risk after surgery, or if you had a traumatic injury with open wounds.

• There is a chance that you could get long-term damage to the knee or ankle joint surfaces, eventually causing arthritis.

Functional disability

As physiotherapists, we look at your injury from a functional perspective. Meaning, how has this injury affected your daily life, whether you had surgery or not. Disability can be described as a disadvantage or handicap that limits a person’s movements and actions. Tibia fractures directly limit the movement of your knee and ankle joint, not to mention the ability to step on your leg. Even if you had surgery years ago, it could still be a problem.

• If your tibia fracture surgery is successful, you will be able to walk and get back into your routine quite soon afterwards. However, if you don’t recover well, it could leave you weak and dependent on a crutch or a walking frame.
• It is possible that your injured leg will be shorter than your other leg after an injury like this. If the fractured bone is damaged, you lose some of the bone tissue. A shorter leg causes permanent difficulty when you walk, like limping even years after you had surgery.
• Even if you don’t need surgery, you’ll have to keep weight off of your leg for the bone to attach. This includes walking with crutches and not exercising. Your body deconditions and you’ll have to work hard on strengthening and get you back into shape.

Our physiotherapists are experts in human anatomy and movement with the necessary experience to diagnose a serious injury to your tibia and shin. If we suspects a fracture, you will be referred for x-rays and an orthopaedic surgeon if necessary. 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 or completely different issues.

During your evaluation, we do movement and stability tests of your shin to pinpoint what is causing your pain. We will also test the surrounding muscles and joints to confirm or rule out other injuries in order to accurately identify where your pain is coming from. This is how we determine the best treatment plan for your specific injury. To prioritize the culprits, set up a order of hierarchy and, changes that must be made to create the a healing environment.

A tuning fork has a sensitivity of 75% and 67% accuracy to accurately locate the site of the tibia bone fracture. This is a inexpensive quick way to know if your tibia is cracked, broken or shattered.

X-rays are effective 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 is crucial to determine the treatment approach.

Your physiotherapist will refer you for x-rays if necessary.

Diagnostic ultrasound is the second option if X-rays are clean. However, it can be very useful to identify signs of a stress fracture by looking for bone bruising, bone oedema, periosteal thickening and even rule out muscle tears, tendon ruptures or ligament sprains.

If you need an ultrasound, your physio will refer you.

An MRI or CT scan shows all of 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.

Initially, after you had a tibia fracture, the pain in your lower leg is normal. The pain serves as a warning and protective mechanism to keep you from doing anything too strenuous. It reminds you that your broken leg still needs to heal. If everything goes according to plan, your pain should decrease as you recover. However, if you neglect to work through a structured program, you’ll continue to feel pain. With time, it bothers you more and more. It even prevent you from walking properly and your leg gets painful, weak and stiff. You become stuck in a cycle of pain, not knowing if it is better to move or not.

Tibial stress fractures are particularly challenging and poorly managed in the medical profession due to it’s biomechanical nature of origin. This means that muscle imbalances, foot alignment, training intensity and many other components gradually fails, one after the other. Your body tries to adapt and accommodate but each tactic eventually breaks down to end up placing more and more crushing and wringing forces through your tibia bone. The mistake is to think that crutches or a moon boot for a few weeks will fix the problem. In our experience that’s just the way to ensure you’ll develop the same problem again. Disperse the force absorption to the surrounding muscles, ligaments and tendons has a much better success rate.

The right treatment from the start

Getting an accurate diagnosis guides the prognosis (recovery time).This includes getting the right medical treatment and working through a proper rehabilitation program. The recovery program after a fracture spends a lot of time fixing the secondary fallout caused by the fracture namely the muscle tears, torn ligaments and ruptured tendons. We rebuild capacity to strengthen, endure and absorb load through the bone in a safe increments.

This is the only way to ensure that you get back on your feet, so that you’re able to walk, climb stairs, drive a car or exercise again. Maybe you feel like you didn’t recover well from a broken shin that happened years ago, because you’re still walking with a painful limp. Don’t lose hope. You can still get help. Your fracture might have healed, but the pain that you are feeling is caused by other problems. Weakness of surrounding muscles, poor knee and ankle stability or even a difference in your leg length are some of the things that can cause pain even years later.

Waiting too long before getting proper treatment

A common problem we see is that patients wait too long before they start working through a proper rehabilitation programme. Often, patients feel they need to rest and recover for a few months after a fracture, when in fact they can start with safe movements quite soon after. With time, you get used to walking with a painful limp or walking with a crutch, and you never fully recover. Now, the problem is a lot more advanced and it will take a lot longer to get better.

Trying out, but not completing different forms of treatment

Often, while recovering from a broken tibia, patients try to get pain relief through medication or injections alone. However, these treatments will only give you temporary pain relief, because you are not addressing the root of the problem. The pain that you are feeling in your lower leg 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 programme. 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.

Resting too much or too little

Resting too much leaves you weaker than before. Moving too much causes extra pain and inflammation. Finding the balance between resting and doing safe movements is key!

Use of crutches

While recovering from a tibia fracture, initially, you might need a walking frame or crutches to walk. Eventually you need to stop using crutches and walk without any help to encourage bone remodeling and hardening. However, people tend to become dependent, weak and unstable. You need to ask yourself the question: “Am I using my crutch because I really need it or am I using it simply because I am scared or too lazy to exercise to get my leg stronger?”

Our experienced team of physiotherapists can help you to find the cause of your shin pain to 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.

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, this is why monitoring by a physiotherapist plays a vital role. To adjust, adapt and overcome temporary setback and keep the momentum 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. This follow-up examination may bring new information to light, like delayed healing or abnormal bone attachment. Your practitioner will adapt your program accordingly.

• Pain medication: Initially, you need medication to manage your pain, but it must be reduced incrementally to not delay tissue healing.
• Cortisone injections: Your doctor might suggest that you get a cortisone injection if your pain persists. This could ease any discomfort and pain from inflammation. However, long-term use of cortisone is not good for the integrity of your joints and if the problem is of a biomechanical nature, it won’t be the solution to your problem.
• Getting a manipulation done: 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 break down bone bridging and put pressure on healing bone.
• Seeing a biokineticist: When you have worked through your treatment plan with your physiotherapist and need help with further rehab, a biokineticist are valuable to help you get take it to the next level.
• A moonboot and crutches: Giving it space to heal properly, without added strain. However, as the bone structure fuses, it must becomes stronger again, you need to increase the weight on your leg. With time, you need to be able to walk without any assistance, or you risk abnormal bone healing or not healing at all.
• Stretches can make the injury worse by putting more strain and tension on the injured bone. It won’t help to try and stretch the pain away.

Chances are that treatment of your tibia fracture are more than 55% likely to involve surgery to fixate the different bone fragments together, with a hospitalization of about 4 -9 days. It’s secures the tibia fragments. An orthopaedic surgeon uses various devices such as nails, plates, screws and rods to stabilise and fixate the tibia fracture. The only type of tibia fracture that doesn’t need surgery is a stress fracture and a distal avulsion fracture. Both of these still needs time to heal and you must walk with a moonboot or a cast to keep the weight off of the bone shaft.

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 day after your surgery. Even if you aren’t allowed to do much, your physiotherapist can help you by passively moving your leg and showing you safe exercises to do. This way, when the orthopaedic surgeon gives you the green light to to start moving, your physio is up to date and ready to progress your treatment.

We work with a network of expert orthopeadic surgeons that has proven their expertise. We can refer you to the best specialist that suits your problem. Even If you are not happy with the physiotherapy you have received after your surgery, give us a call. We can help you with post-operative rehabilitation whether it happened recently or long ago.

• Shin splints – deep, severe ache right against your shin bone that gets more intense and sharper with exercise, especially running.
• Tibialis anterior tendonitis – feels worse when you flex your foot (pull your toes up towards you). Pain usually feels more superficial and sometimes like ankle pain. Specifically sore with movement, not bearing weight.
• Osgood Schlatter’s disease – pain just below your kneecap that feels worse with jumping or getting up from a chair. Better with rest. Often seen in children and teenagers.
• Patella tendonitis – similar to Osgood Schlatter’s, but can happen at any age. Knee movements make the pain worse, especially straightening your knee.
• Knee osteoarthritis – characterized by knee stiffness in the morning and eases with movement as your knee “warms up”.
• Ankle ligament sprain – happens after “rolling” your ankle. A severe ankle sprain can cause an avulsion fracture of the tibia or fibula.

• Proximal tibia fracture
• Tibial shaft fracture
• Distal tibia fracture
• Fractured shin bone
• Stress fracture of the tibia
• Broken ankle
• Knee fracture