Working Diagnosis:
Osteoid Osteoma with associated overlying Anterior Tibial Stress Fracture

Treatment:
She was initially treated conservatively with walking boot and non-steroidal anti-inflammatories and held from sport participation. Due to lack of improvement, her scan was repeated and showed an osteoid osteoma with an overlying anterior tibial stress fracture. She then had the osteoma ablated and a carbon fiber rod placed for the stress fracture in order to limit image artifact if there needs to be reevaluation of the osteoma site. Case Photo #8

Outcome:
The patient has had successful ablation of the osteoid osteoma and surgical rod placement. She then continued through post operative recovery and gradual return to sport for the next year. As of writing, she denied any symptoms, had no evidence of recurring osteoma, and was doing well.

Author's Comments:
Anterior tibial stress fractures are rare but occur in athletes. Due to their location, tensile forces, and blood supply, they usually require surgery. Osteoid Osteomas are benign tumors commonly found in the tibia. They are usually self-limited but can ablated. Both present similarly and are on the differential for anterior leg pain. This highlights a patient that had an osteoid osteoma with an overlying anterior tibial stress fracture in the same location and required treatment for both. Not only is it unique that both pathologies were present, but also, a carbon fiber rod was used instead of the usual IM rod to not distort future MRI images in case they are needed for tumor recurrence.

Editor's Comments:
Bone stress injuries of the tibia exist on a spectrum ranging from tibial stress syndrome to higher-grade stress reactions and stress fractures. MRI is the gold standard for staging. Tibial stress syndrome is characterized by periosteal edema only, while progression may lead to a stress reaction with bone marrow edema. A stress fracture is defined by cortical involvement and the presence of a visible fracture line.

Anterior tibial stress fractures are considered high-risk and, as noted by the authors, often require surgical management, particularly when the dreaded black line is seen on plain radiographs. In contrast, the more common medial tibial stress fracture is typically managed non-surgically.

This case highlights the importance of maintaining a broad differential diagnosis and ensuring appropriate follow-up, especially when the clinical course is atypical, as in this case involving an underlying bone tumor.

References:
Jordan RW, Koc T, Chapman AW, Taylor HP. Osteoid osteoma of the foot and ankle: a systematic review. Foot Ankle Surg. 2015;21(4):228-234. doi:10.1016/j.fas.2015.04.005

Kiel J, Kaiser K. Stress reaction and fractures. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2025.

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