North Dakota State
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Non-traumatic Medical Tibial Plateau Stress Fracture Following BPTB ACL Reconstruction:
A Case Report
Terra Billiet, Dr. Pamela Hansen, Dr. Jay Albrecht, Dr. Jared Tucker
North Dakota State University
Department of Health, Nutrition and Exercise Sciences, Fargo, ND
Abstract
Objective: To discuss the unique formation of a medial tibial
plateau stress fracture following an ACL reconstructive surgery in a
Division I Collegiate Women’s soccer player.
Background: During the fall season, a Division I Collegiate women’s
soccer player tore her left anterior cruciate ligament (ACL) after
being kicked by a teammate. The foot was planted and internally
rotated when getting kicked by the teammate. The teammate
then fell and landed on the left leg of athlete. Reconstructive
surgery was performed using a middle 1/3 bone patellar tendon
bone (BPTB) autograph and a small lateral meniscus tear was also
repaired during the surgery. The athlete had follow up visits with the
team physician, all of which showed the athlete doing extremely
well with no complaints. Five months after starting the rehab
process, soreness on the medial aspect of the knee was noted. Xrays were normal. By mid-April, the athlete was walking with a limp
and had pain on the medial side of the knee. An MRI showed a
stress fracture of the medial tibial plateau.
Differential Diagnosis: patellar tendonitis, stress reaction, screw
irritation, chondral defect, meniscus tear.
Treatment: The athlete progressed through ACL rehab protocol
with no setbacks. When medial tibial stress fracture showed up five
months later, the athlete was put on crutches for about two weeks
until there was no pain during weight bearing. A different
rehabilitation protocol was implemented. The athlete has returned
to her sport.
Background
Uniqueness
 20 year old Division I Women’s soccer player
 ACL reconstruction using BPTB autograph and lateral meniscus repair of left knee due to injury at
practice during the season(19 years old)
o 4.5 months post-surgery, left leg is stronger than right in flexion and extension; physician gives the
go ahead to increase strengthening and start sport specific activity
• athlete did inform physician of a fall on the ice at this check up, but everything was fine besides
an abrasion on the surgical scar, no infection noted
 At 5 months, athlete complains of soreness and slight swelling developed on medial side of knee with
pain during walking, flexing, and extending of knee; referred to physician
 Three weeks later athlete displayed slight anterior discomfort after activities, tender to palpation at
inferior aspect of patellar tendon, mild discomfort doing single leg 1/3 leg bends
o Anti inflammatory drugs were prescribed
o Continued Phonophoresis
o Cho-pat strap
 A week later the athlete had joint line tenderness and was walking with a limp
o X-ray normal
o MRI ordered
Uniqueness: Stress fractures of the medial tibial plateau have not
been documented as occurring after an ACL reconstruction.
 Stress fractures of the medial tibial plateau have
not been documented as occurring after an ACL
reconstruction
Improving Outcomes
 Monitored athlete’s rehab more closely
o due to athlete’s aggressive personality
 Tibial tunnel creating stress riser
o cortical defect significantly decrease the resistance
allowed for torsional and bending forces1
o fractures have been documented to cross the entire
tibial plateau, passing through the tibial tunnel
drilled for the reconstruction of the ACL2-3
 Accelerate rehab protocol surpassed healing of
bone4
o hypothesized that ACL injury reconstruction effects
the metabolism of articular cartilage with it taking at
least one year for cleavage of type II collagen to be
restored to within normal limits5
MRI Images
Conclusions
Conclusions: The possibility of medial tibial plateau stress fractures
should be considered in individuals during the rehab process for
previous ACL reconstructions using BPTB autografts.
 Rare development following ACL reconstruction
surgery
Differential Diagnosis
 Cause may be due to stress riser due to tibial tunnel
or aggressive rehab protocol allowing intensity to
get ahead of the still healing bone
 Patellar tendonitis
 Stress reaction
 Screw irritation
 Watch for in individuals following ACL reconstruction
that show signs of knee pain in the later stages of
rehabilitation when there is more impact on the joint
 Chondral defect
 Meniscus tear
Treatment
References
 2 weeks on crutches
 New rehab protocol beginning with walking,
progressing to cross training with no impact
activities (elliptical, swimming, biking)
o followed by open-chain strengthening and
eventually progressed back to sport specific
activity
 Back to full activity by new fall preseason
• View 1
• View 2
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reconstruction. Knee Surg Sports Traumatol Arthrosc. (2004)12:325-28.
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(2006);13:238-40.
3. Thaunat M, Nourissat G, Gaudin P, Beaufils P. Tibial plateau fracture after anterior cruciate
ligament reconstruction: role of the interference screw resorption in the stress riser effect.
Knee. (2006);13:241-43.
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for sports participation. Sports Med. (2004)34:269-80.
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Rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med.
(2005)33:347-59.