Secrets To Treating Stress Fracture Of The Ankle

By Amol Saxena, DPM, and Andrew Cassidy, DPM

Stress fractures in and around the ankle are most often due to repetitive stress. These injuries are often underdiagnosed and may be misdiagnosed as “shin splints.” In fact, the symptoms may persist for an extended period before the diagnosis of a stress fracture is even made. One reason for this is these types of injuries are often sports-related. Athletes, in general, may have a higher pain threshold and continue to exercise, which can exacerbate symptoms.
At the Palo Alto Medical Foundation, we see a predominantly athletic population in our sports medicine department. Our goal is not only to get them back to a functional level but also to get them back to a competitive level as well.
The term “athlete” is often used loosely for anyone who is remotely active. However, the definition of an athlete needs to be better defined in the literature as to individual training regimens and/or activity levels. Stress fractures of the ankle area are caused by weightbearing repetitive stress and you’ll often see these injuries among athletes who participate in track, soccer and basketball. Football and baseball players may suffer these injuries as well.

Running is the predominant sport for eliciting stress fractures of the lower extremity. Track injuries often happen during times of increased mileage training and/or the initiation of speed work. In addition, they can also arise as a result of a change in running surface. Concrete is about five to 10 times as dense as asphalt and can generate a significant increase in cumulative stress on the bones of the lower extremity, thus resulting in fracture.
In the case of the trained athlete who is running on a regular basis, the osteoblastic activity cannot keep up with the catabolic nature of the osteoclastic cells. In the case of the weekend warrior, the individual’s bone density may not be adapted to a sudden increase of running stress. This is not necessarily an issue of a catabolic/anabolic imbalance, but rather an issue of too much too soon. Athletes who have coaches and are training on a regular basis are more aware of such injuries and are often treated sooner than the weekend warrior. In today’s society, a lot of people train on their own. They may come in to see you when they can’t achieve symptom relief with ice, rest and NSAIDs.

Are Age And Sex Contributing Factors In Risk For Stress Fractures?
Not only is the type of sport important as a possible piece of the diagnostic puzzle but the sex of the patient is also relevant. Women tend to be more prone to getting stress fractures. Although this is primarily anecdotal, we’ve found this to be the case in our practice.
There are some studies providing evidence to support this hypothesis. The increased incidence in females is secondary to a syndrome, often coined as the “female triad.” This triad consists of amenorrhea, osteopenia and eating disorders. While other contributing factors may include low body weight, high training intensity, suboptimal nutrition, physical and mental stress, the three etiological factors of the triad are often present in a high percentage of female runners, according to the research.
Barrow, et. al., found menstrual irregularity has a higher correlation with more stress fractures in female collegiate runners: 49 percent in those with zero to five menses per year versus 29 percent in runners reporting 10 to 13 menses per year.1 Amenorrhea has a strong association with decreased bone density averaging a 4 percent loss in bone density per year and up to a 20 percent decrease per year in some cases.2 Oral contraceptives help offset this hypoestrogenic state significantly and thereby reduce the risk of stress fractures in these female runners. The etiology of this exercise-induced amenorrhea is due to an energy drain on the body and a resulting hypothalamic amenorrhea in an attempt to conserve energy in the body.2
The age of the patient can also be a diagnostic marker for helping to identify those who are more predisposed to these kind of fractures. Younger athletic kids are often prone to stress fractures of the growth plate. These are kids who are usually involved in multiple sports year round.

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