Identifying And Treating Stress Fractures And Lateral Ankle Sprains In Athletes

Ron Raducanu, DPM, FACFAS

   As our population gets more and more active, it stands to reason that they will suffer from more and more sports-related injuries.

   In the adult population, we see this with the “weekend warrior” types, who have not been conditioned regularly to participate in strenuous activity. Alternately, we may see adult patients who take on an exercise regimen without seeking the proper guidance on how to progress in intensity.

   In the pediatric population, we are seeing more injuries than ever since many of these young athletes get no downtime between sports activities. They go from one sport to another without giving their bodies the much needed rest to heal any micro-injuries they may have sustained during the previous activity’s season of play.

   The two most common injuries we see in the aforementioned populations are metatarsal stress fractures and lateral ankle sprains, which also can present with peroneal tendon injuries or frank fractures of the fifth metatarsal.

How To Address Stress Fractures

   Much of the research on lower extremity stress fractures has been in the military population, which has a high incidence of tibial stress fractures, and the population of young ballet dancers, who may suffer from both tibial and metatarsal stress fractures.1 When it comes to stress fractures in ballet dancers, particularly fractures of the second metatarsal, these were initially attributed to a variance in the length of the second metatarsal with respect to the first. However, subsequent research has discounted this theory.2 Stress fractures were also commonly referred to as “hairline” fractures in the past but this terminology has fallen by the wayside.

   Stress fractures involve an excessive amount of stress on a bone that cannot compensate as it should. It becomes an imbalance of the bone breaking itself down via osteoclastic activity and building itself back up via osteoblastic activity. This assumes that there is no pathologic basis for such an imbalance as one may see when there are certain arthridities and/or cancerous pathologies within the bone itself.

   In most situations, a patient presenting with a stress fracture will note an increasing amount of pain in the midfoot. These patients typically say the pain first occurs at rest and subsequently occurs during and throughout their chosen activity. Patients may relate a certain amount of swelling to the dorsum of the foot but will most likely cite pain as the primary complaint.

   One of the difficulties of identifying a stress fracture is a potential lack of physical signs such as ecchymosis, or severe edema and pain associated with a frank fracture. Also be aware that in-office radiographic evaluation may not facilitate an accurate diagnosis. While the “tuning fork test” is somewhat helpful in the attempted diagnosis, it is a rather non-sensitive test and may have a high false negative rate.

   In patients in whom there is a high suspicion of a stress fracture, some alternate testing to consider may include a bone scan, computed tomography (CT) or magnetic resonance imaging (MRI) in order to pinpoint the location and severity of the injury accurately.

   Treatment of a stress fracture rarely involves surgery as this injury tends to respond very well to conservative management. Immobilization in a cast boot is indicated. One may encourage the patient to attempt light ambulation with the cast boot in an attempt to restore the balance of osteoclastic versus osteoblastic activity. However, physicians still need to provide immobilization to help speed recovery.

   Generally, a period of partial weightbearing in a cast boot of four to six weeks should allow the body adequate time to not only heal itself but also restore the balance of bone restoration and bone destruction. If this is not sufficient time to help patients return to their chosen activity, investigate another cause for the injury such as a more systemic etiology.

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