Cath Lab Digest

   One diagnostic test that works well is having the patient hop on the injured side. This produces sharp, pinpoint pain. One may also use the hop test to determine if the bone is healed enough for the patient to return to activity. In the early stages, radiographic findings are usually insignificant so one must follow negative X-rays with further testing.

   The triple phase bone scan (TPBS) remains the most sensitive indicator of a stress fracture. Many physicians favor MRI but there are more false positives with a MRI than the TPBS. When patients have stress fractures of the tarsal bones, particularly the navicular, one should obtain a CT scan in the coronal and axial plane with 1.5 mm cuts in order to ascertain the extent of the fracture and help guide treatment.

   While stress fractures often occur after over-training, multiple stress fractures in an experienced runner require much further investigation. Females require special attention due to the possibility of the female athlete triad of amenorrhea, anorexia and osteoporosis. If one suspects this triad, the clinician should refer the patient for nutritional and psychological consultation. Keep in mind that there will be a significantly high rate of denial in an athlete with this syndrome.

   Pay special attention to the biomechanical examination when patients present with recurrent injuries and inquire about changes in training including possible increases in mileage or the intensity of the workouts. In the colder climates, indoor track and, in the high school population, running in the school hallways, are big contributors to running injuries and increased stress fractures.^14,15

Pertinent Pearls For Treating Stress Fractures

   Conservative treatment of most stress fractures includes no running and only non-weightbearing cross training. Several stress fractures require casting and/or non-weightbearing including the base of the fifth metatarsal, femur, navicular and cuboid. Matheson’s 1987 analysis of 320 bone scans positive for stress fractures found the tarsal bones to be the second most common site, accounting for 25 percent of the positive bone scans.¹⁶

   Navicular stress fractures in particular have been found to occur in runners at a surprisingly high rate. This bears mention as diagnosis and treatment of navicular stress fractures requires a high index of suspicion and eight to 10 weeks of immobilization including non-weightbearing. When conservative treatment fails to heal a navicular stress fracture, one should proceed to open reduction internal fixation (ORIF). Two articles show a faster return to activity following surgical management of navicular fractures than conservative treatment.^17,18

   Bone stimulation is an additional modality that may help get an injured athlete back faster from a stress fracture. There is very little published to support using a bone stimulator but a study by Saxena in Foot and Ankle Quarterly showed that using a pulsed electromagnetic field (PEMF) allowed athletes to return much quicker from their stress fractures.¹⁹ The paper presented a small, prospective, unblended analysis of 73 stress fractures that were confirmed via bone scan, MRI or CT scan. The PEMF group returned to activity in 8.8 weeks versus the non-PEMF group, which returned to activity in 17.6 weeks. Further scientific studies are warranted but even a few weeks of added training can mean a great difference to a professional runner or a college or high-school runner with a limited amount of eligibility to compete.

A Closer Look At Iliotibial Band Syndrome

   Iliotibial band syndrome (ITBS) can be a debilitating injury to a runner. The IT band (ITB), as it is more commonly known, can become so painful that a runner is unable to train at all. The classic symptoms of ITBS are pain along the lateral aspect of the knee joint that is sometimes accompanied by a clicking sensation. The click is a result of the ITB tightening up and snapping across the joint during running. Often, the symptoms are worse when athletes are running up or down hills.